The overburdened midwives in Uganda’s health centres

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At about 1pm, we arrive at Kabaale Health Centre III in Uganda's western district of Hoima after a 51km journey from Hoima city to the health facility.

As we approach the gate, the signpost reads Buseruka Health Centre III, prompting momentary confusion. Are we at the wrong facility?

We soon confirm that we are in the right place. The signage, like many things at the health centre, tells a deeper story.

There is a sizeable crowd gathered at the clinic: mothers, children, and some men — but no health personnel in sight. We search for the midwife on duty and find her. She greets us warmly. She tells us she is alone, and she has worked for 24 hours nonstop.

Kabaale Health Centre III (Buseruka Health Centre III) in Uganda's western district of Hoima. (Credit: Jacky Achan)

Phiona Nabukeera says she is responsible for all maternal and child health services: antenatal, labour and delivery, postnatal care, immunization, and family planning. 

If she is assisting a mother in labour, others must wait. There is no one else to help. That means delays for everyone.

A single nurse also runs the general outpatient clinic. Like the midwife, she too works alone and is the only one available. This scenario is likely the case in many other health centres across Uganda.

Clearly, there is a human resource crisis at the health centre, and its consequences are evident in the long waits and stretched staff. Only one nurse in the outpatient clinic and one enrolled midwife in the maternity wing.

Need for more staff

An enrolled midwife, Nabukeera has been serving at Kabaale Health Centre III for three years. 

She trained as an enrolled comprehensive nurse at the International Institute of Health Sciences and completed her studies in 2012. Later, she pursued an in-service midwifery training course for six months and was eventually recruited. In total, she’s been serving in Hoima district for ten years.

“I have worked in several facilities. This is my first in Hoima. The work is good — we are doing it — but it is hectic, and we are trying to do our best," she says.

There are only two midwives at the health centre. Nabukeera is the junior, while her in-charge, an assistant nursing officer, is not around when we visit.

They alternate 48-hour shifts — each working straight through the day and night for two days before switching. It is a tough schedule, with just two midwives attending to all maternity-related services.

“Some days we attend to 10 to 15 mothers,” says Nabukeera.

"But being alone makes it difficult to give quality care. I handle everything — antenatal, labour, postnatal, and family planning. It is hard to monitor labour properly.”

She says the maternity unit ideally needs four midwives: one for day duty, another for evening, one for night, and one off-duty. "Two people for the day shift would make a difference."

But for Nabukeera, even communicating with patients is a challenge, as language barriers also complicate care.

“We serve people from many tribes — Alur, Lugbara, and others. Sometimes I can’t understand their language and what they are saying. It’s hard to explain things to them,” says Nabukeera, a Munyoro from Kibale district.

“We try to find someone from our staff, the mothers and carers, who can help interpret.”

Policy vs reality

While the World Health Organisation (WHO) recommends that one midwife should handle no more than 175 deliveries per year, in Uganda, that number is double: 350 deliveries per midwife a year to achieve at least 80 per cent skilled birth attendance.

This ratio emphasises the urgent need for a sufficient number of skilled birth attendants, including midwives, to ensure safe and effective delivery care. 

Yet, for a country with a population growth of 2.9 per cent, Uganda is not there yet.

Government policy stipulates that each Health Centre III should have at least eight midwives — but that policy hasn’t been implemented by the public service and finance ministries.

As a result, Kabaale Health Centre III, and likely many other health centre IIIs across Uganda, remains severely understaffed.

On average, the Kabaale facility delivers 35 to 40 mothers a month, far below the expected 93. Some mothers live in distant areas up to 30km away. And because of the long distance to Kabaale, they opt to seek services from other nearer facilities outside the district, such as Kyehoro Health Centre III in Kikuube district.

In Uganda, according to the Ministry of Health, the recommended distance to health facilities should be within a 5km radius of populated areas to ensure accessibility. 

However, this goal remains far from being achieved.

Handling emergencies

Nabukeera encourages mothers to always ensure birth preparedness for a safe and healthy delivery.

Enrolled Midwife Phiona Nabukeera at Kabaale Health Centre III in Hoima district. (Credit: Jacky Achan)

“We also ask them to have transport money, because for a long time we had no standby vehicle for referrals to Hoima Regional Referral Hospital.”

So far, the facility has relied on a good Samaritan with a private car to support transport mothers during emergencies.

“Even at night, we would call him, and he would come and transport the mother. But sometimes I am alone and can’t leave the labour ward to escort the mother.”

When seconds count

In labour emergencies, delays in receiving appropriate care can significantly increase the risk of maternal mortality and morbidity, and timely access to quality health care is crucial in preventing complications and saving lives.

“Take obstructed labour — a mother can be referred, but along the way, she may give birth without proper care — the baby may not breathe and could die from lack of oxygen," explains Nabukeera.

She recounts a case from November last year: a young mother, who delivered twins at home, came in with a retained placenta. Her family opposed referral due to traditional beliefs and had no money. She was bleeding heavily and in a critical state.

“We managed to remove the placenta here with difficulty," says Nabukeera.

"They had no money for transport, and they refused a referral. We contacted her LC1 chairman, who then spoke to contractors at SBC (Uganda) Ltd, a joint venture between SBI International Holdings AG and Colas UK, responsible for the development of the Kabaale International Airport in Hoima; they helped us with transport.

"She was transfused at the referral hospital and survived. Sadly, the twins she was carrying had died before arriving.”

'I have no choice'

Day after day, Nabukeera presses on. One woman. One department. One mission: to save lives, even when she is the only one left standing.

On some days Nabukeera is alone — sometimes for 48 hours — but she does it all: deliveries, emergencies, postnatal care, and counselling. She confesses that long hours compromise the quality of care.

On some days, she has to manage multiple mothers in labour at once.

“If one is on the bed and the other is progressing, I conduct one delivery, leave the placenta in, give a uterotonic, a medication that induces or strengthens contractions of the uterus to prevent haemorrhage (control bleeding), then attend to the next mother.

"It has happened before. It is not ideal, but I have no choice.”

Just three days before our May 2 visit, a local politician, Pius Wakabi, representing Bugahya constituency in Bunyoro region, where the health centre is located, donated a used car with a personalised number plate 'MAPEPULE' for referrals.

But the vehicle sits idle, parked under a tarpaulin in the health centre’s compound. It hasn’t moved. Possibly, there’s no fuel. 

And perhaps the timing of the donation is tied to the upcoming elections – likely an election-season gesture.

Hope amidst crisis

As Uganda prepares to mark International Day of the Midwife on May 5, this year’s theme, “Midwives are critical in every crisis”, couldn’t be more fitting. 

The commemoration will be held in Hoima — right where Nabukeera works alone under immense pressure every day.

Nabukeera followed her inspired passion for midwifery. “I had a spirit for saving lives. I admired how smart midwives looked. I wanted to be like them. By God’s grace, I am one now," she says.

Despite the workload and language barrier, sometimes she finds purpose. 

“When someone recovers, I feel I have helped. I believe I stand in for God. I got this job on merit — others are still searching. Even when I am tired, I keep going.”

Kabaale Health Centre III has 10 technical staff: five nurses, two lab technicians, one clinical officer (in-charge), and two midwives. A qualified but unemployed midwife volunteers regularly.

“She is only 24, and does a great job. We would be so happy if she got a permanent job," says Nabukeera.

Nabukeera is not without regrets, though. Her most regrettable moment in 13 years of service is losing a mother. 

“She came in at night, unconscious, grunting. We tried to refer her, but it was too late. She had severe anaemia. She was only 28 weeks pregnant. I believe if we were properly staffed and had better equipment, she would have been saved.

“If they could just increase the number of midwives, the workload would be manageable, and we could offer better care to mothers,” she appeals.

Still, Nabukeera soldiers on — alone, but undeterred to deliver babies safely, one birth at a time.