This past Friday and Saturday, I went to the Annual Conference of the Association of Obstetricians and Gynecologists of Uganda. The title of the conference was "Advances and Technologies in Maternal Health."
I really enjoyed it. It cost 50,000 shillings ($25) to go, although 30,000 shillings ($15) for midwives, which I was glad to see. The level of discourse was very high, and the topics were very relevant and important.
Sometimes I feel like a lot of research is done (and presented) just to do (and present) research, not because it's a burning question that needs to be answered. And often I think the things that are researched are chosen because they are popular, rather than interesting or valuable. (This is not just in Ob/Gyn, but in a variety of academic fields). But I didn't feel that way at this conference.
The first session was on cervical cancer screening and vaccination. I learned that paps and VIA (see-and-treat methods) are both considered reasonable options, depending on the resources of the region/institution, and there were comparisons of those methods and discussions of their value. I learned that they are using the cervical cancer vaccine in Nairobi, and how much it costs here (about $170 for all 3 shots, which is less than in the US), and there was discussion of whether it is reasonable to use here.
There was a session on misoprostol, which to me was the most exciting. Up until 2 months ago, miso had not been approved for use in Uganda. It's an incredibly inexpensive and safe medication that can prevent or treat hemorrhage after delivery, but it is often not distributed because people are afraid it will be used for abortion (which it can be). Obviously, it's ridiculous to let hundreds of thousands of women die in labor every year because other women might have safer abortions. (A study in the Lancet from October 2007 showed that abortion is no less common where it's illegal than where it's legal. Where there's a will there's a way.)
A nonprofit organization called Venture Strategies has been approved by the Ministry of Health to roll out a pilot program of misoprostol distribution in 11 districts in Uganda. It started in June 2009. I was really excited to hear this, and even more excited to discover that the AOGU was submitting a resolution to call for more widespread distribution of misoprostol throughout Uganda. It was signed with big fanfare by the important members of the AOGU, and later by everyone else.
When I had asked in Tororo District Hospital if they had misoprostol, the head of nursing for maternity had never heard about it. When I described it, she said they would be very excited to get some and try it out, because postpartum hemorrhage is a big problem and they need more medications.
Another talk in the conference was about postabortion care, and I was surprised to hear the speaker say, "Many of us don't want to talk about the difficult subject of abortion because it is uncomfortable, but we must talk about it. Unsafe abortion is the number one killer of pregnant women in Uganda. It will not go away, and so we must talk about it. We must improve our postabortion care services for women because they should not die."
Of course it's not exactly a call to legalize it, but it was a forthcoming and nonjudgmental statement, and there wasn't one objected verbalized in the room.
There was a session on maternal mortality, in which presentations looked a mortality rates in Uganda and in specific hospitals. One presentation looked at decision-to-incision time in cesarean sections, which in developed countries is generally supposed to be 30 minutes or less, with exceptions for emergencies or extenuating circumstances. This presentation looked at the times in a large hospital in Kampala, and found that the average wait time is 7.5 hours. While 30 minutes is not really a viable possibility here, the speaker was arguing that times need to be shorter. He found that to reduce infant morbidity and mortality, a wait time of 2.5 hours or less is ideal, and to reduce maternal injury or death, a wait time of 4 hours or less is ideal. When he looked at the reasons for delay, 91% of the time it was unavailability of surgical space. It was a very dramatic argument and created a good discussion during the Q&A - clearly, more space needs to be a priority.
Another presentation I really liked was an Ob/Gyn who is also a nun, and she works upcountry in Lira. Her talk was about a day in the life of an upcountry Ob/Gyn. It went something like this:
-- 8am start rounds. 48 patients on the wards to be seen.
-- Finish seeing 3 mothers, and receive 4 transfers from health centers
-- 2 of the transfers need urgent c-sections - one for ruptured uterus, one for obstructed labor with fetal distress
-- Do both cesareans, then go back to ward round
--Continue rounding. Mothers to be discharged are getting anxious because they have not been seen, and if they leave the hospital late, they will not be able to get transport home.
-- A postpartum hemorrhage on the labor ward - doctor is called
-- Finish with postpartum hemorrhage, mother is stable
-- Return to ward rounds - it is now 3pm and the nurses want to give report and go home soon
-- Another transfer comes in, needing emergency cesarean
-- Return to ward round, continue rounding alone (nurses have left)
-- Doctor is on-call all night, and must cover entire hospital
It was a very moving presentation, and really made me appreciate the dedication of these upcountry physicians. Every Ob/Gyn in Uganda seems to work very, very hard, but these people are the toughest. According to Eve (my Ob/Gyn friend from Mbarara who I reconnected with at the conference), 90% of Ob/Gyns in Uganda live in Kampala. There are only 20-30 Ob/Gyns outside Kampala.
Another set of presentations surrounded improvement in maternal services delivery, and community involvement. Apparently, two districts, Kibogo and Kibale (I think) were singled out at a previous conference for having the worst maternal mortality in Uganda - around 2000 deaths in 100,000 livebirths. The AOGU at that time took up a resolution to create pilot projects in those districts. They involved the community, conducted education campaigns about the importance of maternal health and delivery, and created Village Emergency Funds for transport to the hospital in emergency cases (many of the women are delayed in making it to the hospital because they can't afford transport). Apparently there was good success with the pilot projects and a reduction in maternal mortality in the districts.
Because of some delays in the schedule, I had to miss out on the talks on malaria and HIV (aargh!) and assisted reproduction (I wasn't too upset about missing that one. Yawn.).
There were some pharmaceutical companies (mostly Indian) there to advertise medications (not nearly as prevalent as in American conferences though), and I picked up some free meds, mostly pain meds and antibiotic creams. But I also got to learn the names and doses of common medications here, because they are all different.
I am really glad I went. The talks were very interesting, the Q&As had great questions and discussions, and it was very informative learning where the AOGU stands on many things, and what it feels is important. It sounds like they are on the right path toward improving maternal health, but there is a long way to go still. I felt really inspired to try to be part of the solution.