It’s not that simple…

by Devin Faris
S.O.U.L. Foundation Global Health Corps Fellow

There are few tools more powerful in development work than the art of listening. However, moving one step further and channeling this tool through rigorous research offers us the unique opportunity to see inside high complex sets of issues. Through our research, we are able to capture reality in a way that no amount of informal observation allows us to do. My co-fellow Viola and I live and work in a situation that allows us to appreciate this contrast in quite a striking way. We wake up each morning in our simple, sleepy house in the middle of our village near Jinja, Uganda, greeting the families outside and walking the muddy roads to our offices at S.O.U.L. Foundation, and are able to observe each family’s struggles, innovations and unique realities. While we can engage deeply with each of these families who continue to accept us into their homes and lives, we cannot adequately compare their stories or experiences in any kind of meaningful and measurable way that can be responsibly manifested into community-based programming. So we turn to our research…

We interview mothers and pregnant women, some as young as 14, about what deters women in the community from delivering their newborns in Uganda’s health centers, what drives them to continue to deliver with traditional midwives (known more commonly by the increasingly taboo label of Traditional Birthing Attendants, or TBAs) and put themselves at risk (granted some of the most skilled and talented midwives I have met are among these traditional midwives – they are miracle workers), and what they wish would change about the Ugandan health system. They say the nurses abuse them, shout at them, even slap them, often failing to serve mothers who have just spent an hour and a half on the back of a boda driving up a muddy road through littered trading centers for their ANC visits, only to have to return home to come back the next day, having not received the care they needed. The mothers are chastised for not bringing the materials they need to deliver in the health center can even be sent to the back of the line while those with the requisite ANC book, kitenge, plastic sheets and gloves get pushed to the front. So we say to ourselves, “the main problem is the attitude and behavior of the health workers.”

But it’s not that simple…

We visit each of the 16 health centers throughout the health sub-district to listen to their workers, the midwives who work tirelessly, short-staffed and overburdened, to meet the explosive maternity needs of this country. They say that when mothers come without the supplies they need and the health center lacks the provisions, they just can’t help them. They say they do everything they can, but they simply do not have the supplies to be able to give to the mothers themselves. They lack the staff to provide care to the dozens of mothers that come for ANC every day, lack adequate supplies of immunizations to offer the women who bring their children for PNC visits, and must break the news to these mothers that they all need to come at once on a designated day when the medicines are available so that everyone can receive these services at the same time. The mothers, they say, are not well enough informed or mobilized to be able to interface with the health system. So we say to ourselves, “the main problem is that women lack the proper information and mobilization to make the most of their health center visits.”

But it’s not that simple…

We hold focus group discussions with the Village Health Teams in each of our 11 sample villages across the health sub-district. These are the community health workers – the first level of the Ugandan health system – charged with the task of mobilizing women to attend ANC visits, to bring their newborns in for postnatal care and immunizations 6 weeks after delivery, and for supplementing the information given to them at the health centers. The VHTs express how they are supposed to be coordinating for these women to come to the health facilities on the designated days in order to be properly served, but since the inception of the VHT program in 2010, in-service training for each team has been minimal at best. The required 10 VHT members in each village has dwindled to the 2 most active, known as Community Medicine Distributors, leaving the rest of the VHTs out from any trainings or continuing medical education opportunities from the Ministry of Health or NGOs like Marie Stopes or TASO Uganda. Without training, without means of transport, without any sort of compensation or incentives to keep working in the community, the VHTs are barely able to do the work that they are intended to do. So we say to ourselves, “the main problem is that every level of the health system lacks the appropriate training, supplies and resources to be able to adequately assist the women in the community.”

But it’s not that simple…

We go to the District Health Officials and ask them about how they are addressing the issue of limited supplies, poor attitudes of the health workers, low staff attendance, and limited training opportunities for VHTs. They tell us that each district only gets a certain lump sum each quarter from the Ministry of Health, and that it is in no way enough to meet all the needs expressed by the health workers throughout the health sub-district. They tell us that the amount they receive depends on the needs conveyed through district reports, but these reports have to come from the lower rungs of the health center and have to be submitted in a timely manner in order for any action to be taken. Reporting mechanisms throughout the district are weak, and their ability to properly advocate for what the district needs remains limited. So we finally say to ourselves, “Clearly there is no main problem, but rather a complex set of interwoven issues that are holding women in Uganda back from accessing the care that they need.”

It’s never that simple.

Simply talking to women, or merely listening to health workers, or observing the work of VHTs, or reading reports of the performance of the district health system will never offer the full picture that such comprehensive data collection can provide. Each challenge leads to recognition of a new challenge altogether. This is the driving reason why data must be the first step in quality programmatic efforts in any context. Without such a robust study, we would never be able to provide S.O.U.L. Foundation with the full picture of what women are up against in the health system in eastern Uganda. And of course, it’s still not that simple…

While our data measures these various maternal health indices, it does not measure the sheer breadth of the myriad challenges and epidemics that women face all over this country: domestic and gender-based violence, sexual abuse, workplace discrimination, sex work, trafficking. These are hurdles that women continue to confront the whole world over, and we know our research is only the tip of the iceberg. For now, for what we cannot measure, we know that all we can do is observe, and observe deeply, as these women open their doors, their hearts and their worlds to us each and every day. We believe that our conversations with them empower them to speak their stories, their truths, their voice. All we can hope, through programming or through that very simple act of listening, is that those voices are amplified. The more we listen, the more we learn, and the more we learn, the more we can work together to change this country, and this world.

March 1st, 2012- A Day to Never Forget at the S.O.U.L Birthing Inn/Midwife Center, By Brooke Stern

Today was a remarkable day. A day I could have never planned. A few hours of sheer joy and excitement. A few minutes of heart racing anxiety. A few seconds of uncertainty. An afternoon with an incredible outcome.

As I drove back from my fishpond project site to S.O.U.L.’s main office in the village of Bujagali Falls, I decided to stop in to visit Kalimentina, the local midwife I have been passionately supporting for the past 10 months.

Anyone who knows me, knows about the undying passion and love I have for Kalimentina- a woman in her late 60’s who has been delivering babies since 1974. She is the only midwife in the area and delivers between 5-7 babies per day, thought most of the deliveries take place at night. She is a women filled with incredible energy, kindness, and love. She will tend to women at any time of the day and night, and rarely gets anything in return from the villagers.

When I first visited Kalimentina’s birthing center, the roof was leaking, the door was made of cardboard and the windows were broken. There were no beds. No sheets. No materials or supplies- NOTHING! Devastating to see, S.O.U.L has since redone her roof, installed solar panels to provide electricity, put in 3 brand new iron doors, 3 glass windows, 4 mattresses, a bed frame, locks for her doors, gloves, medical supplies, a water collection system, and painted the inside, which is still the bare minimum.

I arrived at Kalimentina’s around three in the afternoon to find her relaxing on the grass, chatting with some other women. Seeing me pull up, a huge smile spread across her face as she walked to greet me at my car. We began walking to the birthing hut to sit and chat but before we could sit down, a young woman came screaming and running towards us, speaking in the local dialect. Kalimentina, barefooted, and barely dressed, grabbed my arm and pulled me as she started to sprint deep into the village, bushwhacking, and listening to the villagers as they informed her as to what awaited us.

I follow. Her stride gets faster. At this point, I am trailing a 60+ year old, and gasping for air. Kalimentina leads the way as others follow us, anxious to help. Up the hill, around the corner, lying on the red dirt a women suffering in pain comes into view. At this point, we are almost a half-mile away from the birthing center. We circle around her and realize that her water is about to break. We lift her, each on one side, and start sprinting with her down the path, out of breath, as each of her arms drape over us. Her pain increases, so we lay her on the red dirt. Once the pain subsides, she chooses to walk, a testament to the toughness of Ugandan women, and we guide her carefully, but with a fast stride, to Kalimentina’s birthing center.

We make it to the clinic with barely a minute to spare, as her water breaks. The beds are disheveled and still unmade following two deliveries earlier in the day. We grab anything we can- garbage bags as sheets, a plastic bag to put beneath the delivering mother, and one cotton cloth. That’s all there is. Kalimentina gives me her 2nd to last pair of sterile gloves and the adrenaline is high. There is NO pain medicine, as is the case in most Ugandan clinics.

The woman starts screaming “mammmmmaaa, maaaaammmmaa Mzungu (white person).” I rush over to her, helping her through each contraction. She is within minutes of delivering when another women enters the clinic in desperate pain. As Kalimentina tends to her, I realized I needed to improvise and grabbed anything in sight. There are no medical instruments. No sheets. No tourniquet. NOTHING. I grabbed a black garbage bag, put it under the woman, took the package from the gloves and used it to clean the area, used an old glove to act as a tourniquet, and a razor blade to cut the umbilical cord (when the time came).

The contractions got closer together. I called Kalimentina over, but she said this one was all me! I said, “Mama Kalimentina IDA SOW WENA (Mama, come here now, fast).” She reiterated that she only had one more pair of gloves, and it had to be used for the next woman, so I had to do this on my own. She encouraged me, saying, “you already delivered two babies in the past, you can do this!!”

Understanding with my whole being that this was a life or death situation, I sat down between her contractions, and yelled push in the local language over and over. And she did. Kalimentina is quiet and calm and confirms my actions when I feel unsure. She is a soft-spoken, confident woman who knows more than I would have ever expected. With the next contraction, the head started crowning. The screaming got louder, the pain grew, and as the head emerged, I grabbed it and slowly rotated the body, pulling the baby out in a clockwise direction to assure the limbs came out together. I was sweating, the woman was quietly gasping in pain, the mother of the woman in labor was screaming in joy and praising me, as I pulled the baby out!!! The umbilical cord was wrapped around the baby’s neck 2 times, and I was terrified. I started to panic. Kalimentina assured me everything was ok. I held the baby in one hand, and unraveled the cord in the other, and within seconds heard that amazing, wonderful, reassuring CRY from the baby. What a relief. A HEALTHY BABY BOY WAS BORN!!!!!!!!!!!!

-Brooke Stern, RN, Co-Founder and CEO