Millennium Promise - Extreme Poverty Ends Here

The realities of life without midwives are stark: a pregnant woman in Africa has a 1 in 22 chance of dying, in sub-Saharan Africa, the situation is worse: 1 in only 16. In North America, it's 1 in 3,800.

Midwives in Ruhiira address a host of related health issues, since they are trained in the prevention of mother-to-child transmission of HIV, prenatal/childbirth/antenatal support, neonatal care, and family planning services. In Ruhiira's six clinics, midwives serve approximately 11,000 pregnant women per year, improving the lives for as many families.

But caseloads are high and hours are long: each midwife cares for about 350 women per year and we expect each woman to visit a clinic at least four times over the course of a pregnancy. Currently, 28 midwives receive government salaries (which can be as low as $150/month), hardly enough incentive for trained personnel to brave the community’s harsh rural conditions. Additional funding support will supplement salaries, reward high performance, provide training and help to hire new midwives thus reducing caseloads to a manageable size, to ultimately increase the quality of care for women and babies.

The midwife project, combined with other key health system services, will have a profound impact on women’s and children’s health.

Before the Ruhiira community joined Millennium Villages, childbirth presented a serious risk to mothers, with only 8% of mothers delivering at health units, 74% at home, 18% by traditional birthing assistants who have no medical training.

Now, health interventions run by Millennium Promise—including six newly renovated clinics, improved facilities for emergency obstetrics, and the community health worker program that provides follow-up care at home—reduce disease, transmission of HIV, and maternal and infant mortality for about 100,000 people in the communities around Ruhiira, Uganda.

After two years, the Ruhiira community has made great strides on Millennium Development Goal #5: Improve Maternal Health and has significantly impacted Goal #4: Reduce Child Mortality.

The women in this photo have a lot to smile about. On the right, the woman wrapped in a bright green shawl has just given birth. She and her baby are doing great, thanks in large part to her midwife on the left, who wears the signature midwife's cap and white nurse's uniform beneath her black leather jacket.

It's a scene that's replayed daily in the area's six clinics.

But only two years ago, before the Millennium Villages project, most women did not have the luxury of a medically supervised birth. The best they could hope for was help from a "traditional birth attendant:" a neighbor or relative with no medical training. Back then pregnant women in the area had a 1 in 16 chance of dying, the same as the rest of sub-Saharan Africa.

There's no doubt the midwives are proud of the difference they are making. Jennifer Twikirize, another midwife in Ruhiira, is glad to be on a winning team: “Through the Millennium Villages Project, we have definitely helped reduce the death of pregnant mothers and infant mortality in the community.” That’s no small achievement for an area where, before Jennifer and the midwives arrived two years ago, less than 20 percent of women had medically supervised births.

But for Jennifer, the successes go beyond statistics. “Through the routine sensitization programs I conduct, mothers are now aware of the importance of antenatal care and regular checkups unlike before, they are now quick to report any complication as soon as they notice anything. We also give regular health education to pregnant mothers on how to care for new born babies.”

Personally, says Jennifer, “I’m now living my dream, what I studied to be. I love my profession and I’m motivated because I’m doing what I wanted to do since childhood.”

When Natukunda Monica of Kamubizi village—a farmer and mother of three children--prepared to give birth to her fourth child, she was ready to try something different. “My first deliveries were with a traditional birth attendant because the health centers then were in poor condition.” Traditional birth attendants or TBAs are neighborhood women who help deliver babies, even though they have no medical training.

Despite the well-meaning efforts of TBAs, without medical expertise, they can do little to reduce the risks of maternal and infant deaths. In sub-Saharan Africa, a pregnant woman has a 1 in 16 chance of dying. But her fourth pregnancy was different. Six health clinics in her district had been refurbished and fully staffed. So Monica traveled 9 miles each way for prenatal visits at the closest, Kabuyanda Health Center.

“Despite the large number of patients, I have been visiting the health center and the midwives.” Visits require a long day because of time spent traveling and waiting. But for her, the effort was worth it. Ms. Natukunda says she was grateful to find doctors and medical personnel at the health facility knowledgeable and polite unlike in the past. She finds healthcare has greatly improved, since her community joined the Millennium Villages.

So, when Ms. Katukunda went into labor with her fourth child, her husband organized a boda-boda cyclist to take her to the health facility. Part of African bicycle culture, boda-boda taxis started in the 1960s and 1970s. The name originated from a need to transport people across the "no-mans-land" between border posts in Uganda and Kenya, without the paperwork involved with using motor vehicles crossing the international border. This started in southern border crossing town of Busia (Uganda), where there is over half a mile between the gates and quickly spread to the northern border town of Malaba (Kenya). The bicycle owners would shout out boda-boda (border-to-border) to potential customers.

On arrival, Ms Natukunda was rushed straight away to the delivery room and gave birth to a healthy baby boy. She and her baby are pictured here with midwife Babirye Monic. In just two years, zero maternal death was registered in the Ruhiira cluster health facilities which serve a population of about 140,000 people. Health awareness and early health-seeking behavior among the community has greatly improved.

Check back to see how the project is doing, and remember to encourage your friends to consider making a donation.

This photo shows how people in Ruhiira cook in a typical Ugandan kitchen. The stoves or firepits can be very inefficient, burning large quantities of fuel, and sending unhealthy fumes into the air. Replacing those stoves with fuel efficient, low-emission models will improve the deforestation of the environment, air quality and lung function for people. Stove replacement is just one of the many holistic initiatives that the Uganda team's science coordinator discusses in the interview below, when he explains why the project is so successful.

What is your role in the project?
My name is David Siriri, the Science Coordinator of the Ruhiira Millennium Villages Project. I am responsible for ensuring sound technical design and implementation of project activities in a way that responds to the project model and community priorities. I also conduct measurements, monitoring and activity evaluation to generate data that informs project design and track achievement of project targets.
What progress has been made since 11/30/2009?
The community health workers continued to be the first responders in providing basic treatment and referring patients to health units. As a result, prevalence and severity of malaria continued to decline while monthly child births in all health units now stands at over 400. The project registered zero maternal death in the cluster during December 2009. The emergence medical response system has been strengthened with nurses trained in emergence handling and ambulance dispatch. The operating theatre at Kabuyanda health unit is now functional after a few months breakdown. Clinical staff have been trained in use of medical equipment donated by General Electric and can now perform scans for better pregnancy management. The number of households using water treatment chemicals has increased after an initial cultural resistance. As a result, the diarrhea disease burden at health units has decreased. Villagers started using improved cook stoves introduced by MVP. This has reduced indoor air pollution which causes respiratory tract diseases and has saved up to 45% of cooking fuel wood in families using the stoves. New roads were opened and old ones rehabilitated, increasing accessibility to markets and health units.
How important is this project to you?
My biggest motivation is seeing people’s lives transformed. I have for the last 12 years worked with different research and development agencies but never before has my work made real community transformations like at the Millennium Villages Project. What is different here is having an integrated holistic approach to development in which all issues affecting human livelihoods are tackled at the concurently, empowering communities to take lead in planning their future and investing their own resources in implementing their chosen interventions, and having significant development assistance that reaches the intended target. These key ingredients have combined to bring hope and dignity to the many lives that were bound by shackles of extreme poverty.

One great thing about getting involved with a Millennium Village in Uganda, is that there’s a lot that people in the developed world can learn about the amazing social organization and mutual support that can be found in rural Sub-Saharan Africa. The most local level of organization is the village that consists of 50 to 70 households and 250 to 1,000 people, depending on family size. Everyone participates in a local council, which is governed by a chairman and a 9-person executive committee.

Before any village joins the Millennium Village project, the local council must vote to participate, select key initiatives to work on, and contribute 15 percent of project costs. Here’s how one LCI (local committee level 1) chairman views the Millennium Village project, from the perspective of the area’s very first village, Ruhiira—this is where the initial research was conducted and where residents first voted to join the Millennium Villages.
An interview with Tindyebwa Johnson, Farmer and LCI Chairman Ruhiira cell:
“Before the MVP project came, we were badly off. We lacked good health services, the roads were poor and inaccessible, the schooling conditions were very poor and generally life was miserable. The MVP has within a short time done what would have taken government over 100 years to do. Now we have enough food to eat and we are making good money from selling bananas because the roads are now very good and farmers have been involved in several trainings and are now in registered groups. The health facilities are now fully functional and well equipped, classrooms have been built and children can now eat at school.

Me as a person, I am now seeing great change in the community, business is now moving fast. I now find it easy to lead my people because the services are good. Many of our community members have now got jobs because of MVP, some of the facilitators, enumerators, health staff, radio staffs have got jobs”.

My name is Naomi, and I am an intern with Millennium Promise Japan, assigned to the Ruhiira project. Recently I spent a morning with Helen, one of two resident midwives at the bustling Ruhiira Health Centre, and I'd like to share one of the stories I heard with you.

One of the women who came in during my visit with Helen was 20 year-old Stella who is expecting her third child, seen here in this photo with Helen the midwife. She says, "third child," although the first two children tragically died during labor. Both times, Stella labored at home without medical assistance. Discovering this, Helen immediately began making arrangements for Stella's next birth to be conducted via C-section at the operating theatre in the Kabuyanda parish of the village.

Then Helen thoroughly examined Stella. She tested for HIV, Stella tested negative! She checked Stella's hemoglobin levels, and took her blood pressure. After determining Stella had strong vital signs, Helen advised Stella about good nutritional practices during pregnancy. Then she felt for the position of the baby’s head and they even let me listen to the baby's heartbeat! Helen is optimistic that this next birth will be problem-free. “Now I know her situation and her history, I can keep a close eye on her progress,” says Helen, and she schedules an appointment for Stella for next week.

Stella truly embodies the way the Millennium Villages project transforms lives and restores hope to people for whom hope was running out.

“I test, I review, I advise, I treat– and I’m a mother myself," laughs Helen. "I often feel like I’m doing the jobs of three people!” Indeed, despite her receiving an average of 10 expectant mothers per morning and being on call for labors and deliveries 24/7, I watch her greet each expectant mother with a big smile. I’m truly amazed by her energy! What’s more, as gender issues remain something of a challenge, I also see her playing the role of supportive husband, and it’s clear the women in her care depend on her for a lot more than some pills and a blood test.

Since midwives were introduced to the clinic in 2007, not one mother delivering in the clinic has died during childbirth, a wonderful example of progress being made towards achieving Millennium Development Goal #5: Improve Maternal Health. The project team credits both an excellent level of pre-natal care and to midwife assistance during labor.