Uganda: midwives shortage hinders efforts to prevent HIV in children

Every day Mercy Nanyonga wakes up, she knows that she is going to help a pregnant woman bring new life into the world.

Every day Mercy Nanyonga wakes up, she knows that she is going to help a pregnant woman bring new life into the world.

Nanyonga, 40, is a midwife at Bugamba Health Centre IV in Mbarara district, south-western Uganda. Some days, she is the only midwife on duty at the facility which serves seven sub-counties.

When asked her how many expectant mothers she attends to in a day, she says: “It depends. Sometimes a dozen, other days about 45.”

Demand for enough midwives

Around 1.5 million women give birth every year in Uganda, and currently only around 57 per cent of women have a skilled birth attendant at delivery (UNICEF).

Dr Ampaire Justus, a gynaecologist at St Augustine community medical centre, says: “Uganda will not achieve zero transmission of HIV from mother-to-child, if there are no midwives to provide the necessary care needed by HIV-positive mothers.”

Midwives are key players in preventing the transmission of HIV from mothers to their children. Through counseling they educate expectant mothers on ways to reduce risk to their unborn babies.

However, a mother who finds only one midwife on duty is likely to spend a whole day at the health centre waiting. She may subsequently not come back the following day.

“The government should recruit more midwives to fill the gaps and to help expectant mothers who are HIV positive adhere to treatment,” says Justus.

Option B+ under threat

Joan Kilande, program officer at Coalition for Health Promotion and Standard Development (HEPS), says: “Often if an expectant mother is not attended to when she comes to a health facility, she will stay home and seek the services of a traditional birth attendant. But the traditional birth attendant has no experience in initiating a new born baby on Option B+ if a mother is living with HIV.”

Option B+ is a prevention strategy to eliminate transmission of HIV from mothers to their babies. It involves putting pregnant HIV-positive women on HIV treatment for life immediately, regardless of their CD4 count.

The Option B+ has had significant success in reducing the number of new infections from 27,660 in 2011 to 9,629 in 2013. It has reached more than 1.7 million mothers of whom 7.2 per cent were HIV positive. But while 71 per cent of the positive mothers received antiretroviral medication, only 36 per cent of the exposed infants received treatment (HIV and AIDS Uganda Country Progress Report, 2013). At least 20 per cent of new HIV infections in Uganda still occur from mother to child transmission (Avert).

Musa Bungudu, UNAIDS country coordinator, believes Option B+ is not as successful as it should be. “About 40 children are born with HIV every day in Uganda. All HIV-positive mothers should be counseled on the risks and benefits of different infant feeding options,” Musa says.

HIV counselling for mothers

Maria Najjemba, country midwifery advisor for the United Nations Population Fund, says: “For mothers to adhere to antiretroviral medication they need close monitoring. Therefore if few midwives are available, the close monitoring is not there and this affects adherence which may lead to treatment failing.”

On top of this, fatigue from being overworked can cause some midwives to express a negative attitude to clients, who may shy away from future visits.

Tony Mugasa, reproductive health advisor for the Ministry of Health, says: “The number of mothers we get is high compared to the midwives we have. They are working day in, day out. They are helping mothers deliver in labour and also attending to mothers coming for antenatal check-ups at the same time. They get burn out and mothers get impatient and run out.” Mugasa urges expectant mothers to be patient should they find only one midwife on duty, encouraging them to revisit the following day.

Recruiting midwives

If the government hopes to reduce the number of babies contracting HIV it clearly needs to commit more resources, train and recruit more midwives and retain them for adequate service delivery.

Recently the Swedish Ministry for Foreign Affairs launched a global ‘midwives4all’ campaign to run across seven countries, including Uganda. This campaign is meant to increase the number of midwives who are trained and also absorb those who have trained but not yet engaged.

For midwives like Mercy this is welcome news as her current workload can be overwhelming. She says: “The labour ward is full of mothers delivering. I deliver four women at once. You rush from one person to another.

“It seems our young generation does not like midwifery as a career. But we need them on board to fill the gap. This campaign I believe will help to address the shortage of midwives in health centres.”

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