By Annette Kanyunyuzi, President, National Midwives Association of Uganda and Hadijah Nakatudde, Executive Midwife Leader, International Confederation of Midwives (ICM)
Midwives are key front-line workers serving clients who seek sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) services. But like many other health workers, they struggle with low staffing, exacerbated by the imbalanced provider-patient levels, clients that live far away from health facilities, and the need for a close and long relationship with their clients.
It is in this regard that midwives should embrace and champion self-care because it can help their clients manage their own health, improving access to healthcare and facilitating more effective and efficient deployment of scarce midwifery resources. According to the World Health Organisation (WHO), self-care includes; “evidence-based, high-quality drugs, devices, diagnostics and/or digital interventions that can be provided fully or partially outside formal health services and used with or without a health worker.”
The Sustainable Development Goal (SDG) of health for all and the targets are in sight but still unmet in several countries including Uganda. In Uganda, there is a need to reduce maternal mortality from 336 to less than 70/100,000. Closing this large gap (among others) highlights the dire need to strengthen the pursuit to meet the set SDG targets, if Uganda is to achieve universal health coverage (UHC). As Uganda works towards achieving UHC, self-care can play an important role by empowering individuals, families and communities to act as informed agents of their own health, to prevent disease and to treat illness, with or without the support of a healthcare provider.
Midwife Victo provides an enlightening experience. One morning, I inquired from Victo what she thought about Uganda’s low performance for post-partum family planning. With exhaustion written all over her face, having delivered 12 mothers the previous night, Victo stated they would like to offer these services, but are overstretched with many mothers who end up missing these services even when the supplies are available. This is a common characteristic across many facilities in Uganda; one midwife in Uganda conducts between 350 and 500 deliveries per year; more than twice the 175 deliveries recommended by WHO. One midwife in Uganda serves a population of 2,000 people while WHO recommends two midwives for every 1000 people to achieve 80% skilled birth attendance. Such gaps in staffing levels are confirmed by the public sector health workforce staffing report 2020 that indicates the staffing level for Nurse Midwife Professional at 58%.
Furthermore, the national health workers (doctors, nurses or midwives) per 1,000 population (at 1.82 per 1,000) is still below the WHO recommended standard of 2.3 health workers per 1,000 people. Staffing deficits at all levels affect quality of services in terms of low uptake, limited availability, poor accessibility and generally low client satisfaction. All these contribute to the vicious cycle of poor health outcomes.
WHO recommends national adoption of self-care as critical to attaining UHC, promoting health, keeping the world safe, and serving the vulnerable amongst our communities. If more women and girls embraced self-care, midwives can have ample time and resources to care for other critical needs of women and girls. It’s important that individuals are given the opportunity to take lead and play an active role in shaping their health to improve health outcomes of the nation.
In the context of access, cost and availability of health care services, remarkable health interventions are practiced by individuals outside of the formal health system, even after visits to a health facility. Self-care interventions such as family planning, self-injection, self-testing, and the use of digital health apps are gaining momentum. Benefits cited include convenience, privacy, time and limited waiting time in lines that is common at the health facilities. These and other evidence-based self-care strategies help in preventing unwanted pregnancies, unsafe abortions and sexually transmitted infections. When women and families are empowered to take lead and participate in decision-making, the quality of antenatal, delivery, postpartum and newborn care is bound to yield more fruits towards safe motherhood, allowing midwives to focus time on the mothers with the greatest need.
There are still challenges faced by the women and girls that result in delayed interventions related to their inability to exercise autonomy over their bodies and are unable to make decisions around sexuality and reproduction given the cultural settings in our country. This calls for midwives to provide a safe space for self-care for such women. Midwives also deal with vulnerable groups such as adolescents who will need more support and empowerment to make informed decisions about uptake and use of self-care interventions, without being judged. Self-care enables privacy and confidentially as women and girls access contraceptives, pregnancy and HIV-testing, use apps to manage their menstruation and access sexual and reproductive health and rights information, among others. Safe linkage between independent self-care and access to quality health care for vulnerable groups is critical to ensure that self-care remains safe for all on our path to UHC.
Despite all these benefits, In Uganda, there is a need to build the capacity of health workers in understanding the self-care concept. Self-care products should also be available to clients for use when and where they need them. Government needs to create enabling regulation and ensure commodity security for self-care products. Government also needs to enact supportive laws and policies to ensure that patient and health worker rights are upheld.
To raise awareness among members about the benefits of self-care to health workers and products available on market, the National Midwives Association of Uganda (NMAU) conducts webinars, mentorships and provides reference resources to midwives and clients among others. NMAU is also engaged in advocacy to the Ministry of Health and other stakeholders to provide free or low-cost self-care products for the local market.
While some health workers duly worry about the low level of literacy, widespread adoption of mobile phones or the growing use of mobile money have already shown us that when something they deem useful and empowering is introduced to them, they have the innate capacity to understand and adopt such technology and teach others. Midwives can champion self-care by educating more women and girls about emerging self-care practices and products, as Uganda and other countries strive to attain UHC and health for all by 2030.