Tororo hospital on site for maternal deaths (2023)

• Relatives of former patients at the facility say they have lost loved ones due to the carelessness of health workers and corruption.

Dominic Ochieng, a resident of Akadot Subdistrict in Tororo County, is still struggling with the loss of his wife and an unborn child.

Elizabeth Aswan died on February 23 at Tororo General Hospital, where she had been taken to give birth.

If thatMonitorWhen I visited the family home, grief weighed heavily on the well-kept homestead. The house consists of a modest shamba which is well maintained and dotted with fruit trees and pines providing ample shade. Atop Aswan's tomb in its humble surroundings lies a wreath of fresh flowers, preserving the lasting remnants of their years of life.

Dejected Ochieng tries to put on a brave face while recounting the events of that fateful day.

“My wife was in labor and I took her to Tororo Hospital where she was admitted. After a while, a nurse asked me for some money, but I told them I didn't have any at that moment. The nurse told me to do whatever I could to get some money. I decided to leave the hospital to look for the money. I left my mother and sister to take care of my wife. At home I sold everything I had and got some money," he says.

He adds: “Unfortunately, when I returned to the hospital, I found my mother and sister crying. I asked what the problem was and they told me the nurse had informed them that my wife and child might not survive. So they suggested giving her a blood transfusion. I wanted to speak to the nurse but was informed that my wife had died. I checked it myself and indeed my wife and child had died.”

The body was then taken to the morgue, where Ochieng was asked to pay Shs40,000 for treatment.

Patients have the right to impartial access to medical care in government health facilities. In the event of a medical emergency, a person is entitled, under the Hippocratic Oath, to unconditional emergency medical care without the need to pay a deposit or fee prior to medical care.

The principles of the Hippocratic Oath are still held sacred by physicians to this day.

"Treat the sick to the best of your ability, maintain patient privacy and pass on the secrets of medicine to the next generation," the oath reads in part.

According to Ochieng's report, his wife was denied the right to health care at Tororo Hospital and the consequences were fatal.

"I came home to arrange for the bodies to be transported. The police helped transport the body to Mbale for autopsy and we returned home where it was buried. After the funeral we opened a case against the nurses and took the autopsy report to the police, who promised to call us. So far I have never received a call from the police. I am appealing to the government for justice to be done to me,” he says.

The maternal mortality rate for women aged 15 to 49 in Uganda is 368 deaths per 100,000 live births, compared to 438 deaths per 100,000 live births in 2011, against a target of 70 deaths.

Despite this significant decrease, major bleeding accounts for one in four maternal deaths worldwide, and in Uganda bleeding accounts for 46 percent of all maternal deaths. There is evidence that the skill and diligence of healthcare providers are critical to preventing loss of life.

Therefore, Ochieng's ordeal brings the competencies of the health workers at Tororo Main Hospital into focus. According to Joram Okook, a relative of the deceased and a city councilor who represents Morokatipe subdistrict's claims, the autopsy results have given Ochieng's report more credibility.

"When they realized that the situation had deteriorated, they tried to get her to the theater quickly, but unfortunately she couldn't make it. Both the mother and the unborn baby. I found out about the girl's death and the two bodies were selected and taken somewhere in Akadot to where the girl got married," says Okook.

He adds: "I was there on the day of the funeral on February 24th and when I found out how the incident happened I said it was criminal." At the time I called RDC Mr. Nixon Owole. I took a statement to the police. That's why we asked for an autopsy to be performed."

He continues: “I objected to the post-mortem at Tororo Main Hospital because that is exactly where the incident happened. I asked for the autopsy to be done in Mbale and the police cooperated.”

The autopsy might not have been carried out without Okook's intervention.

Maternal deaths are common in Tororo's ramshackle 200-bed government facility. The health facility serves a catchment area of ​​500,000 people, stretching to and beyond the Kenya-Uganda border. The six-bed maternity ward employs two to three obstetricians supervised by one to two doctors who are barely able to care for the patients who require their services.

Obstetricians collect patient information by completing handwritten birth registers at admission and discharge. It's those hospital records that bolstered Okook's sense of injustice.

“The autopsy report came out and accused the hospital of negligence. I'm taking the hospital to court so we'll leave no stone unturned in our quest for justice. We cannot rule out bribes either. Once they were arrested and then released on bail. There were three nurses and a doctor. It was actually the people who were on duty that day,” he says.

Francis Odoi, a nurse at Osukuru Health Center III, took his wife Christine Maliza Mukisa, a 34-year-old mother of four, to the hospital when she went into labor. However, she later died. Odoi says the sight of her grave still pains him.

The sense of loss is palpable as he recounts the events of that fateful day.

“I accompanied my wife to Tororo Hospital and we arrived around 8:30 am. I went to the delivery room and met a doctor, midwives and two other mothers. When they finally called my wife, they said she wasn't [ready to give birth]. My wife later went back to the health workers and was told she would [be ready to give birth] at 2:00 p.m. However, when she gave birth outside the delivery room at 9:45 a.m.,” he says.

He adds: “People gathered and the midwives rushed them into the delivery room. The baby was given oxygen. At 2 p.m. my wife started bleeding profusely. I tried to enter the suite but was chased away by the health workers. They said she was bleeding so badly and they wanted to refer her to Mbale Regional Referral Hospital. I was told to buy medicine to stop the bleeding. I rushed into town to get the drug.”

He goes on to say: On the way back they called me and said I would hesitate and they would remove her uterus. They told me to hurry up and sign [the documents approving the operation]. When I finally got to the hospital I was told that an ambulance was on its way to pick us up and take us to Mbale. I waited until 5 p.m. but no ambulance came. Then they told me that blood had been brought from Nagongera and they would try to help her, but added that they were not sure if she would be able to. At 6 p.m. they told me she had died.”

Moses Mugwe, the spokesman for the Bukedea South region, said thatMonitorthat Mukisa's death was a result of ill-considered and negligent behavior by health workers.

“This matter was reported here and investigated in February 2023 and the files were forwarded to the office of the DPP (Director of Public Prosecutions). The Tororo-based prosecutor recommended that the matter be settled administratively.”

Delays in accessing appropriate treatment in health facilities increase the risk of maternal mortality. These delays are caused by a lack of medical supplies, equipment and adequately trained health workers, affecting the timeliness and quality of medical care for expectant mothers.

The delays Odoi experienced at Tororo Hospital are a symptom of the fragility of the public health system in a country where there is one qualified healthcare professional for every 1,000 people.

This has forced some expectant mothers to seek services outside of government institutions.

Tororo Hospital has a two-room operating room.

“In November 2022 I went into labor and I went to the hospital and they asked for Shs 300,000. I told them I had 200,000 Shs. It was a cesarean operation. I ran out of the hospital and found a traditional midwife to help me deliver for Shs 50,000,” says one mother, who asked to remain anonymous.

Decreasing healthcare budgets have led to a cyclical crisis that is accompanied by acute staff shortages, apathy and depression among underpaid medical workers.

George Olowo, Nyangole Subdistrict LC3 Chairman, shares his wife's experience with some medical workers at Tororo Hospital.

“My own wife went to the hospital to give birth. She carried everything with her, the polythene, the mama gear and the money. After giving the nurse money, the nurse disappeared,” he says.

This experience is corroborated by Peter Okoth, a resident of Nyakesi in Zone A, Nyangole Subdistrict. According to him, the practice of soliciting bribes and blackmailing vulnerable patients is rampant at the facility.

Okoth relates that it was only after parting with money that he received the treatment and care of his pregnant wife.

"Around noon I got a call from my sister and she said there was a nurse who said the baby was not sitting well in the womb and she needed an injection. I knew what the nurse was talking about. Then I asked my sister to ask the nurse how much she wanted," he says.

In Uganda, it is common to bribe health workers for services in health facilities.

Households pay an average of Shs106,000 in bribes to gain access to healthcare, according to a 2021 Inspectorate of Government study. Typically, those in need of maternal services were asked to pay Shs 15,000.

Juliet Ayo, a human rights activist in Tororo, says the situation is dire for the lowest strata of society.

"We advocated that doctors and nurses wear name tags so that if someone asks you for money you cannot afford and you report them to our practice, you can identify them. But they don't report these cases to us. I have a case in court where we sued the hospital for imprudence and negligence. The nurse missed a vein in a boy's hand and had to amputate the hand," she says

Simon Peter Okongo, Nyake Central's LC1 Chair, says this creates a situation where both the giver and the receiver are guilty of corruption.

Crucially, staffing norms in public health facilities in Uganda have not been adjusted in the face of the growing population, increasing the likelihood of staff overload.

In this context, government efforts to increase the use of maternal health services in public institutions are being undermined.

dr Okoth Obbo, Tororo District Health Officer, says: “I cannot confirm or deny that maternal deaths in our facilities may discourage or deter mothers from giving birth in our facilities. But these deaths don't happen every day, they happen every now and then, and we realized that some of the mistakes were made by ourselves and some by the mothers themselves."

He adds, "For example, a mother comes in and we take her details, but by the time it's time to deliver, she's nowhere to be found." They either dropped out temporarily or self-dismissed. We suspect they go to traditional obstetricians, where they are given herbs to speed up the process. But when they return to the hospital, they will be in bad shape and it can lead to the death of the mother.”

He goes on to say, "Some of these deaths are inevitable, others are the result of mistakes from which we learn. When there are issues with our employees, we encourage them to let us know, or we are prepared to listen in trust."

dr Obbo also says there are other factors such as the distance from the expectant mother's home to the health center that hamper the delivery of services.

“Because of the distance, access to these maternal health services is hampered. So they deliver either with the help of traditional obstetricians or from home. Expectant mothers prefer traditional midwives to our midwives because they have a personal touch. Their customer care seems to be better than ours because our midwives are overwhelmed, they are busy, they do not dedicate personal attention to these mothers and yet they need personal attention.”

Investing in the healthcare sector reflects the trend in healthcare-seeking behavior as more and more people seek services in private healthcare facilities. The government has prioritized investment in private healthcare services such as Lubowa Hospital, where the government has allocated US$379.71 million (Shs 1.4 trillion) for the project.

The situation at Tororo General Hospital, as elsewhere, stands in stark contrast to the immaculate First World hospitals where the political elite, their children and friends are flown in for treatment with taxpayers' money, a practice akin to medical apartheid. It is a practice that public watchdog organizations are demanding and must end.

Focused

A 2020 Supreme Court ruling found that the government's failure to provide health care to expectant mothers constituted a violation of their right to health and was unconstitutional.

The court also found the government's failure to provide emergency services to expectant mothers in public health facilities, which resulted in injuries and inhumane treatment, to be unconstitutional.

The court ordered the government to budget adequate funds for maternal health care. This landmark ruling set a precedent as it emerged from a lawsuit filed against the government following the deaths of two mothers-to-be. Rhoda Kukiriza and Inziku Valente.

Steven Masiga, a researcher, cites these legal precedents when proposing remedies.

“We encourage those harmed by the inefficiency of health workers in Tororo to contact them legally. Once you have a duty of care, the law places a duty on you and you are failing to comply with that duty. It's a criminal offense," Masiga told this publication.

“When hearing cases in which medical personnel are charged with rash and negligent acts that led to death, courts in Uganda typically base their judgments on autopsy evidence showing that the cause of death was rash action or negligence of physicians.” workers in question,” he adds.

This is of no consolation to Ochieng and Odoi, who may not have the resources to hire an attorney or understand the procedures for lodging a complaint with the Uganda Medical and Dental Practitioners Council, which then meets and decides whether to authorize an investigation.