Earlier this year, the United Nations Population Fund announced that Uganda’s maternal mortality rates had reduced from 435 deaths per 100,000 live births to 310 deaths per 100,000 live births. This showed that the country had made some progress in bringing down deaths women suffer when bearing a life.

A cursory look at the figures makes for good reading, but a deeper probe shows that Uganda is still some way off from achieving Millennium Development Goal No.5, which implores countries to reduce maternal mortality to at least 151 deaths per 100,000 live births. In fact, statistics from the Uganda Demographic Health Survey report of 2011 show that the maternal mortality ratio increased from 435 deaths per 100,000 live births in 2006 to 438 deaths.

Women continue to die from preventable causes like infections, over bleeding and abortions. Many of them cannot reach health centres in time, while more continue to die at home because they do not deliver with the help of a skilled medical personnel. Uganda has the third fastest growing population in the world, behind Niger and Yemen, with an annual growth rate of 3.2 percent (every woman having an average of seven children).

Dr Charles Kiggundu, an obstetrician and gynaecologist, says there are two million conceptions in Uganda every year, but between 200,000 and 300,000 of these miscarry or abort spontaneously. A further 350,000 abortions are induced.

“Ninety thousand of the induced abortions end up with severe complications, but only a half of them access post abortion services. Only half of the women with complications seek medical care. A few survive, but many others die,” Dr Kiggundu says.

One of the sure ways to reducing maternal deaths in Uganda is by preventing pregnancy through provision of contraceptives to women who need them. Currently, the unmet need for family planning stands at 40 percent.

Indonesia case study

Fifty years ago, Indonesia was on the same standing as Uganda — her population growth was high, women were dying and the fertility rate was high. The country realized that the problems of population and development are basic problems if Indonesia wants to provide better living conditions for its people.

To reduce population growth and maternal deaths, Indonesia’s leaders realised that some controls needed to be instituted. So, they started the “Two Children are Enough” campaign to encourage families to have no more than two children. The campaign needed a national leader with a vision and a comprehensive approach — one who understood the social-cultural aspect of the people.

President Suharto provided the needed support. The campaign also needed a leader in the population field, who would be able to communicate population-related issues, including family planning, to relevant stakeholders. To achieve its goal, the National Population and Family Planning, Indonesia (BKKBN) mobilized members of rural communities to participate in program planning and in the provision of services.

Since clinic-based services were inadequate in reaching a large number of people in the countryside, the family planning programme engaged in widespread outreach and community participation at the village level. At the peak, the rural programme included nearly 40,000 field workers and more than 100,000 volunteers.

“The rural family planning personnel typically would make home visits to discuss family planning methods, provide counselling, and make referrals to community health centres. An innovative, strategically designed, large-scale, multi-pronged, and long-term communication campaign was designed to create a small-family social norm, to increase people’s interest in having fewer children, and to generate demand for family planning services,” says Dr Eddy Hasmi, BKKBN director of international training and collaboration.

The “small, happy, and prosperous family” campaign message became the unifying theme of all programme communication materials at all levels.

The campaign slogan “Two children are enough” became etched in stone —literally, as bridges and mile posts on the major highways carried the it — and eventually became embedded in the national consciousness. The strategy in rural areas was outreach through interpersonal communication that engaged communities through the combination of fieldworkers, health providers (including village-based midwives), and community-based volunteers.

To encourage self-reliance in rural areas, the programme built up the role of private sector midwives. The initiative trained 50,000 village midwives who provided family planning. Dr Sugiri Syarief, head of the population body, says BKKBN came to report directly to the president and was placed in a stronger political position in its coordination with other governmental agencies.

Reaping benefits

As a result, the percentage of family planning clients who obtain their contraception from the private sector grew from less than 18 percent in the early 1980s to an estimated 69 percent in 2007. Dr Hasmi adds that when the programme was implemented, fertility declined sharply, from 5.6 to 2.2 births per woman during the 1970s-2000s.

“This decline has slowed population growth and hence reduced its effects on public services such as education, health and infrastructure, and then has brought improvements in standards of living,” Dr Hasmi says.

“At the family level, wanted children bring joy and social and economic benefits to their parents, while unwanted births unnecessarily raise family expenses for food, clothes, shelter, schooling and health care, as well as time devoted to childcare and rearing,” he adds.

The family planning programme has successfully averted around 100 million births. It was indicated that if the programme had not been successful, Indonesia’s population in 2010 would be about 326 million. Thanks to family planning, it was 237.6 million that year. During the 1970s and 1980s, Indonesia trained nearly 700 PhD and Masters students in population issues, both overseas and within the country.

The programme also developed effective mechanisms for quick resource disbursement. Furthermore, the management also developed data and reporting systems and built research capacity so that program decisions could be based on evidence and scientific analysis. Starting this year, family planning has been integrated into universal coverage of the maternal and neonatal health program that was launched by government in 2011.

This programme was introduced free of charge for prenatal, delivery and antenatal care, as well as family planning postpartum, in health centre facilities for all families. As a result, there are between 4.2 to 4.4 million births per year in Indonesia. In addition, intrauterine devices (IUDs), condoms and implants are provided free of charge to all couples that need them. Thus, in Indonesia today, with the exception of pills and injectables, contraceptives, including long-term contraceptive devices, are provided free of cost.

What next, Uganda?

In July, President Yoweri Museveni finally threw his weight behind the family planning campaign when he announced that his government is committed to increasing family planning options and reducing maternal deaths. Some $5m will be provided every year for the next five years towards access to contraceptives.

While 90 percent of the population has knowledge of family planning, contraceptive use is still very low. People do not value small families and hence do not use contraceptives. Dr Olive Sentumbwe, family health and population advisor at the World Health Organisation in Uganda, says communities need to realise the effect of many pregnancies on a woman. Every pregnancy leaves a woman scarred for life, yet more families continue to have children they cannot take care of.

More women continue to die during pregnancy, child birth and post natal. If Uganda could take a leaf from Indonesia, we might avert maternal deaths and, at the same time, reduce on population growth, which is projected to reach 60 million by 2030 and 100 million by 2050.

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The Observer – Uganda