Why are maternal health outcomes worse for migrant women in Masindi, Uganda?

Globally, 298,000 women die due to pregnancy related causes each year and half of these occur in Africa. In Uganda, maternal mortality has marginally reduced from 526/100,000 to 435/100,000 livebirths between 2001 and 2011. The presence of a skilled attendant during the entire continuum of care for maternal and new born care has great potential to reduce maternal and new born morbidities and mortality.

In 2013, an intervention to mobilize communities in Masindi, Uganda for maternal and new born health was introduced and the results showed marked improvement in utilization of maternal health services such as antenatal care and health facility delivery. However, non-indigenous populations were found to use maternal health services less compared to the indigenous populations. The non-indigenous population are mainly from the West Nile region of Arua and Nebbi. This group of people provide a cheap source of labour for the sugar plantation and sugar factory in Kinyala. This study could not adequately explain why migrants were using maternal health services less.

Poverty, educational level, distance from health facility and costs of transport to and from health facility are recognized as barriers to access. Cultural and traditional practices have also been recognized as reasons for high maternal and neonatal mortality. Most data comes from general populations, without disaggregating barriers in access for different groups.

The aim of this study was to gain a deeper understanding of internal migrant’s low access and utilisation of maternal and new born care services in Masindi, Uganda. Key barriers to access are discussed below.

Barriers to access maternal and new born services

Lack of financial resources: Low-income levels for men and women and high  delivery costs appeared to be a common reason for low utilisation of delivery services. Women said they relied on crops in the gardens and when it is planting, weeding or harvest times, they do not have money enough to procure essential requirements for delivery:

“Our major problem has been money, you may start experiencing labour and you fail to transport yourself to the hospital, even our husbands don’t have proper jobs. This alone has made women to sit back and deliver at home, if there is money every woman will want to deliver in health centre.” (Respondent 1, FGD 2).

The cost of delivery care is expensive and requires buying the essential items required for delivery. The cost of 20,000 shillings required for a ‘mama kit’ for delivery is considered to be high and the expense is sometimes considered unnecessary by the women since they can even use old materials of cloth for receiving the baby:

“When you go to the health centre to deliver they tell you to prepare with delivery items like mama kit and new things like clothes, basin.  As said earlier delivery comes with a lot of demands, what demands? They tell you to buy mama kit, cotton wool, kavera, gloves, yet to raise money as transport is a problem for our husbands yet that small transport to take you to the health facility cannot be raised, many of us are used to giving birth at home now, someone will say let me save this money for other things, even I use it as transport many other things are not bought, at home even without these things you can give birth…, on an old ‘kitenge’ you can deliver, in the health centre nurses will just chase you.”(Respondent 5, FGD 2)

Social beliefs: Community members perceive it to be cowardly behaviour for a woman to rush for care at the health facility during childbirth. Endurance of labour pains is considered a sign of a strong woman and delivering without the help of a second party is received as a heroic action:

“Here the moment you move on to seek care from the health unit the community members insult you by calling you a coward and saying that you are only married because of the bed service but for other issues you are not a woman.”(Respondent 5, FGD 4)

In order to fulfil the community norm of being a resilient woman, some women do not inform their husbands on time about labour, and instead keeps quiet until labour pains intensify. It is only when they are about to reach the second stage of labour that they communicate to their husbands, usually by such a time they are about to deliver within the next thirty minutes. One respondent said, for example, that she went on normally with her house chores and garden activities for the entire day until the labour pains were strong and she soon delivered.

Neglect by health workers: Neglect by health workers was a common complaint by respondents. Some of the male respondents explained that their partners are treated in a manner that they feel is degrading:

“Nurses on many occasions abuse the women that they are stupid and do not know anything to do with deliveries coupled with that is lack of attention for example recently a woman was to deliver she came to the health unit with a helper, on reaching the health unit no one gave her attention not until the helper decided to take her home but she ended up delivering on their way back, this made bad record of the health centre.” (Respondent 7, male FGD)

Respondents were strongly convinced that the main reason for neglect, discrimination and mistreatment by health workers is related to their ethnic differences. The women explain that when they reach the health facility health workers first identify their ethnicity by looking through their names or their ability to speak the local dialect. Sometimes a simple greeting in the local dialect is used as a ‘screening tool’ to separate indigenous from migrant population:

“For example I am a Lugbara, another mother is an Alur and then a Munyoro mother. If a nurse came and asked us in Runyoro only one mother will reply, those who do not answer back in the language will be abandoned, the Munyoro mother will be attended to first. At that moment, you will automatically know that she was picked because of tribe, you become timid, they will even start barking at you because you cannot explain your problems, even when nurses talk, you don’t understand.” (Respondent 1, FGD 1 women group)

Neglect by health workers is perceived to be an indirect means of demanding informal payments from the women. Informal payments influence the health workers to adjust their reception from being rude to be being very caring:

“The nurses asked me for money…they said if I don’t have money they will not help me, they asked for 20,000 which I said I did not have, one of them said I should give 15,000… they started working on me very fast as soon as my husband paid the money.” (Respondent 5, FGD 1 women group)

The problem of informal payments is so critical that women who do not provide the money demanded are denied access to care. One woman, for example, witnessed a migrant woman get off the delivery bed because she could not afford the fee.

Education: Level of education was also seen to influence the type of treatment women received at health facilities. Some women believed that having a higher educational level reduced the risk of discrimination by health workers. However, some respondents argued that indigenous women with lower education levels are treated better compared to immigrants of the same low education level meaning that lower education level alone could not adequately explain their mistreatment:

“It is not education but I think it is because we are from far, because even uneducated Banyoro are attended to very well.” (Respondent 1, FGD 1 women group).

Lack of male involvement: The responsibility of care during pregnancy, labour and childcare has been relegated to the women to the extent that women are held responsible if something goes wrong with the pregnancy. Women are expected to purchase all the requirements needed for delivery. While for the men their responsibility in pregnancy is to buy items for the new born baby, remind their spouses about antenatal care. A minority of the men and women agreed that few men fully support women throughout pregnancy, labour and childcare. Some men are reported to take concern about their sick spouse and even arrange for transport and escort them to the health centre. Others purchase all the requirements needed for delivery and provide special feeding for their spouses

Conclusion

There are a number of barriers to access to maternity care among migrant women in Masindi, Uganda. These barriers can be addressed at two levels. At the household level, there should be deliberate efforts to engage with men to support their partners during pregnancy and childbirth for example, by saving money and preparing for transport to the health facility in case of antenatal care and delivery. At the district level, there is need for district local managers together with district health managers to create a dialogue platform in which communication barriers and the mistreatment of migrant women can be addressed in the health sector.