Nabaloga had been in labor for two days with a traditional birth attendant (TBA) out in a village before the TBA referred her to Kiboga Hospital. Bul she didn't have the money for transport, so she remained in obstructed labor for two more days before finally making it to Kiboga somehow. Her uterus had ruptured and the baby was dead. When the doctor did the C-section he had to do a hysterectomy as well. She only had two children at home and, despite her slate of illness, she seemed most preoccupied by what her husband would think of her, no longer able to bear children.
-Author's fieldnotes, October 24, 2001
Nabaloga's story was one of many I heard during my stay in Kiboga, Uganda. I had traveled to this rural area to live with a family in Butemba, a village about five miles from Kiboga town, and to do an internship in the maternity wing of a government hospital-all research for my undergraduate thesis at Marlboro College in the United States.1 As time went on, as I heard more and more stories like Nabaloga's, common themes began to emerge: lack of financial independence, lack of power, and a sense of self-worth closely tied to fertility. While numerous barriers impede access to health care for every Ugandan, women face an additional set of obstacles as a direct result of their gender. Though the health status of the general population in this East African nation is low, women suffer the most from ill health. Yet they have the least access to health services.
Located just seventy-five miles northwest of Kampala, Uganda's capital city, Kiboga town serves as the political and medical center for the district's population of 171,000 people (Republic of Uganda 1991). Referred to by many as the 'forgotten corner' of Uganda, Kiboga is surprisingly remote, given its proximity to the capital city. Throughout the district, only 1.3 percent of households have electricity2 and 0.7 percent have access to safe drinking water3 (Republic of Uganda 1991). There are no phone lines district-wide, and even cellular phones have no reception. Education levels are low (only 16.9 percent of fifteen-year-olds have completed primary school) and life expectancy at birth is nearly five years less in Kiboga than in Kampala (44.7 versus 49.5 years). Not surprisingly, Kiboga's fertility rate of 7.4 children per woman exceeds the national average of 6.9 and far surpasses Kampala's average of 5.2 (Republic of Uganda 1991). During my stay in Butemba, I lived with a married couple that had nine children, ranging in age from four days to fifteen years.
Perhaps the most visible and devastating obstacle to accessing health care in Uganda is the general lack of transportation and communication infrastructure across the country, as shown in Nabaloga's story. Kiboga is primarily an agricultural area and its population is scattered throughout the countryside. Small villages are connected to each other and to the main town by bumpy dirt roads that are barely wide enough to accommodate a car. Automobiles are rare, though; the preferred mode of transportation for privileged inhabitants is the bodaboda (moped) and, for the majority of the population, bicycles or walking. In rural areas, the most common mode of transportation to a health clinic is a bicycle-clearly not the ideal for someone who is already in a physically compromised state, not to mention someone who needs emergency care. During Uganda's rainy seasons (September to November and April to June), these roads become difficult to traverse and are occasionally even impassable. The 1995 Safe Motherhood Needs Assessment, conducted by the Ministry of Health with support from the World Health Organization, revealed that, in most areas, the local 'ambulance' was a bicycle pulling a trolley, or a stretcher that could be carried to the nearest health center (Republic of Uganda 2000, 22-23). With no way to contact the nearest health center when an emergency arises, the patient often arrives at the hospital only to find staff that are not ideally prepared for the event. Valuable minutes are lost while the doctor is summoned, the operating room prepared.
Communication lines are important not only in emergency situations but also in transmitting to the community crucial health-related messages and information about the value and use of available health services. Rural women are the most disadvantaged in this regard, as they often have no access to newspapers, radio, or television, and they are more likely than men to be illiterate. (Fifty-five percent of Ugandan women cannot read or write compared to thirty-five percent of men [Neema 1999, 100]). Further compounding the communication dilemma is the fact that health promotional materials are often written in English, which few people in rural areas can read or understand (Neema 1999, 100).
The disproportionate number of government health centers located in urban areas exacerbates the transportation and communication difficulties that many patients face. The Ministry of Planning and Economic Development estimates that less than half of Ugandans (49.0 percent) have access to static health units (Republic of Uganda 1991). Over 50 percent of hospitals are located in urban areas, where 11 percent of the population resides, and in 1992 urban areas housed 76 percent of all doctors, 80 percent of midwives, and 70 percent of nurses in Uganda (Republic of Uganda 2001, 7). When one considers the dearth of medical professionals to begin with-the doctor-to-population ratio in Uganda is 1:28,000-this unequal distribution is even more alarming (Republic of Uganda 2001, 7). Attracting health professionals to rural areas has proved to be a daunting task for the Ugandan government. The majority of physicians I came to know at Kiboga Hospital were stationed there involuntarily, fulfilling a mandatory term set by the government to work in a rural area. Specialist physicians on one-month rotations fill the sole position for an obstetrician-gynecologist at Kiboga Hospital. Health professionals' reluctance to live in rural areas is easy to understand when one compares health facilities available in Kampala and other urban areas to what is found in rural areas like Kiboga.
Often called 'the pride of the district,' Kiboga Hospital appears at first glance to be not much more than a dilapidated building; a road sign concealed by rust and dirt announces its presence. Yet this hospital is the most impressive health center in the area; it serves about 15,000 people per year, though its patients are disproportionately from subcounties closest to the hospital (Kiboga Hospital 1999). Even though Lyantonde subcounty (where I lived) is only six to seven miles from Kiboga town, residents of the area often spoke of the hospital as an impossibly distant last resort, inaccessible to most of the local population.
If a patient is able to overcome the numerous barriers to reaching a government health unit, she or he finds upon arrival a limited range of services offered. Ministry of Health statistics from 1998 show that only two-thirds of health units provide ante-natal care, less than half offer maternity services, and only 39 percent have the capacity for inpatient care (Mugaju 1999, 128). As the district's largest health center and the one responsible for tertiary care, Kiboga Hospital is expected to offer a broad range of services, such as X rays, laboratory tests, immunizations, and microscopy for tuberculosis diagnosis. Yet the reality is that many of these services are not always available. Grossly underfunded, like all public hospitals in Uganda, Kiboga Hospital often runs out of such basic supplies as latex gloves and essential drugs. It is not uncommon for women who have had Cesarean sections on Thursday, or later in the week, to go without the antibiotics necessary to prevent sepsis; the hospital often runs out of such drugs by Wednesday, and most women do not have the financial resources necessary to buy the drugs from private pharmacies. More often than not, the hospital has no blood supplies, and patients who need emergency transfusions are referred to Hoima Hospital, fifty miles away. Kiboga Hospital is unable to provide transportation to patients referred to Hoima; those patients who have already faced difficulty scraping together sufficient funds to travel five miles from their village to Kiboga town may very well not make it to Hoima.
Several sociocultural factors place women at greater risk than men, both for becoming ill in the first place and for delaying (or never receiving) health care. Uganda's female morbidity rate is staggering; Stella Neema, at the Makerere Institute of Social Research, reports that over 70 percent of the country's women are sick at any one time (Neema 1999, 96). Though morbidity rates are notoriously difficult to estimate accurately, there is no doubt that a large portion of Ugandan women are suffering suboptimal health. Yet these women have little opportunity to improve their health status. Since cultural preferences dictate that men eat the best food, women already living in malnourished communities have the worst nutrition of all. This inequality persists despite the fact that pregnant and lactating women are most in need of balanced diets to prevent anemia-an especially dangerous condition for pregnant women. Repeated, frequent childbearing compounds the problem (Republic of Uganda 2000, 51). In the household where I lived, on the infrequent occasions when we ate meat, the father enjoyed first claim, followed by the children and the mother (even though the mother was breastfeeding her infant twins at the time).
Once women do fall ill, restoring their health can be a low priority in the family's budget. Often women seek health care solely in relation to their reproductive health, partly because their societal value is closely linked with their fertility, and partly because these are the services offered to them, frequently at the expense of other services. Since most women have little or no independent income, the decision of whether or not they will seek health services rests largely with a woman's husband. Women account for 70 to 80 percent of Uganda's agricultural workforce, yet only 7 percent of them own land and only 30 percent have access to or control over the proceeds of their work (Republic of Uganda 2001, 7). Nationally, only 15 percent of women are self-employed or employed in the formal sector, and nearly all of these women live in urban areas (Republic of Uganda 2001, 7). Women work an average of fifteen to eighteen hours each day, compared to the eight to ten hours that men work (Neema 1999, 102). They often cannot afford to leave their domestic duties for a day to seek health care. Even where public health care is free, transportation to the health unit and sometimes the need for additional drugs can cost women money they do not have, requiring the notification and consent of the husband. This lack of financial autonomy becomes especially crucial in relation to family planning services.
The consequences of this lack of access to services are partially evident in high mortality rates; the infant mortality rate in Uganda is 97 deaths per 1,000 live births, compared to a rate of 6.9 deaths per 1,000 live births in the United States (and mortality rates in the United States are among the highest of all developed countries). The maternal mortality rate is equally staggering, at 506 deaths per 100,000 live births, compared to 7.5 deaths per 100,000 live births in the United States (Republic of Uganda 1991; Centers for Disease Control 2002a, 2002b) .4 The Ministry of Health estimates that, nationally, only 38 percent of women are attended by a trained health person during childbirth; it is safe to assume that in Kiboga this number is even lower (Republic of Uganda 2000, 3). Indeed, among the many pregnant women I met in Butemba, not one intended to have a hospital birth. The majority of women deliver at home, with the assistance of female relatives, older children, and sometimes a traditional birth attendant.
A striking 22 percent of all maternal deaths are caused by unsafe, illegal abortions, according to the Ministry of Health (Republic of Uganda 2001, 9). Although this societal problem could partly be addressed on the policy level by legalizing abortion, the number of deaths from clandestine abortions could be significantly reduced if proper post-abortion care were available; today, only 30 percent of health units offer such care, which is needed for both induced abortion and spontaneous abortion (miscarriage) (Republic of Uganda 2000, 20).
Available family planning services often fall short of the ideal. Anthony Mbonye, commenting on Uganda's low contraceptive prevalence rate of 15 percent, estimates that over three-quarters of Ugandan women lack access to family planning services (quoted in nSalasatta 2001, 30). Those who do enjoy access to family planning may not receive adequate counseling, follow-up care, or access to the full range of contraceptives they deserve. Hardon et al. call for minimal requirements in the range of contraceptives offered that include methods for both men and women; temporary and permanent, hormonal and nonhormonal, user-controlled methods (i.e., the Pill and barrier methods); and methods that are safe for breastfeeding women. They also call for postcoital methods, such as emergency contraception and abortion (the latter, as mentioned, is illegal in Uganda and the former is practically nonexistent) (Hardon et al. 1997, 32). Yet these ideals, though often embraced in theory, are rarely delivered in practice. In Kiboga Hospital, I observed that, by far, the most common contraceptive given to women is Depo Provera, a hormonal injection that provides protection from pregnancy for three months. A survey of the clinic revealed that the only other options available are the Pill and condoms.
In the face of such dire health conditions, what have international donor agencies and the national government done to try and improve the situation? Development efforts in the field of women's reproductive health have largely been misdirected and ineffective. Undue emphasis has been placed on curbing fertility levels via aggressive family planning campaigns, rather than on addressing the forms of structural inequities that lead to women's disempowerment. When the United States Agency for International Development (USAID) first came to Uganda, they were not willing to put resources into any non-family-planning programs. Now, with domestic and international pressure, the agency is slowly widening its focus to related issues, like safe motherhood.5 Still, despite gains made after the 1994 International Conference on Population and Development (ICPD), donors place disproportionate emphasis on promoting family planning as the chief strategy for fertility reduction. Donors are less willing to fund basic supplies and equipment other than contraceptives (gloves and drugs, for example) at health centers, even though such support would dramatically increase the quality of services offered and decrease mortality rates.6
If the newly adopted language of 'improving women's reproductive health' from the ICPD is to be taken seriously, then the government and donors alike need to address barriers to health care access both within the health care system and external to it. Women have a right to comprehensive health services and not merely services aimed at reducing their fertility. In order to achieve this, health centers need to be adequately equipped with essential supplies like gloves and drugs (particularly antibiotics), in addition to basic amenities like running water and electricity. Health centers should be committed to providing a wide range of health services and not only those related to controlling women's fertility. Within family planning services, women have a right to truly 'informed choice' from a full range of contraceptives, including user-controlled, nonhormonal methods. Beyond the health care system, improvements in infrastructural elements, like roads and communication lines, would directly benefit women's health. Likewise, increasing women's access to financial resources would ease their dependence on men when it comes to making health-related decisions.
Returning to Nabaloga, whose story opens this essay, we can see that the health care system's failure to help her is by no means a random occurrence. A multitude of factors combined to impede her access to health services and her ability to give birth to a healthy child. Without adequate means of transportation, financial resources, and the power to make decisions regarding her body, this woman had few opportunities to avoid the tragedy that unfolded. Faced with the loss of her child, she has to cope with the additional stress of questioning her status in society now that she cannot bear any more children. This woman, like so many others, is more likely to fall ill than the men in her family, and she is less likely to receive adequate medical care. Efforts to 'empower' these women solely through increased access to contraceptives drastically fall short of what is needed. Women in Kiboga, like women in many developing countries, will have difficulty claiming power over their bodies and health care decisions until fundamental changes, both inside and outside the health care system, take place.
NOTES
1. The name of the village and subcounty in Kiboga District has been changed.
2. Compared to an average of 2.6 percent in the rest of Uganda, excluding Kampala, and 5.6 percent nationally.
3. Compared to an average of 23.6 percent in the rest of Uganda, excluding Kampala, and 25.7 percent nationally.
4. The risk of death from pregnancy in developing countries is 1 in 16, compared to 1 in 1,800 in developed countries (Republic of Uganda 1999, 2).
5. Assistant commissioner of Reproductive Health, personal communication, March 18, 2002.
6. Project manager, Reproductive Health Division, personal communication, April 2, 2002.
[Reference]
REFERENCES
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_____.(2002b). 'Maternal Mortality-United States, 1982-1996' http://www. cdc.gov/\epo/mmwr/preview/mmwrhtml/00054602.htm. Accessed November 14, 2002.
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nSalasatta, Dan. (2001). Bear children by choice, not chance. The New Vision. October 10. 30.
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_____. (2000). Reproductive health division 5-year strategic framework 2000-2004. Kampala, Uganda: Ministry of Health.
_____. (2001). National adolescent health policy. Entebbe, Uganda: Ministry of Health.
[Author Affiliation]
Lara Knudsen graduated from Marlboro College in Vermont in May 2003. She plans to pursue a career in medicine and public health. She is currently working on a book about women's reproductive rights in seven countries.
Copyright � 2003 by Lara Knudsen
