Dr Christopher Garimoi Orach MBChB, MMedPH, MPH, PhD Makerere University, School of Public Health
During two decades, 1986-2009, of civil war between the rebel Lord's Resistance Army and Uganda government forces, an estimated 1.6 million people were displaced into encampment - internally displaced persons (IDPs) camps in northern and eastern Uganda. The districts in the Acholi sub-region bore the brunt of the war. The vast majority 95% or 678,000 inhabitants of the districts of Pader and Kitgum districts were displaced. A total of 67 internally displaced persons camps were established in the two districts.
Worldwide, there are an estimated 15.6 million internally displaced persons and 10.4 million refugees. The vast majority of the displaced populations live in Asia 4.3 million and 2.6 million in Africa (UNHCR 2010). The health of displaced populations is affected by several underlying factors including insecurity, socio-economic and health systems. Although all displaced persons are vulnerable, women and children are the most vulnerable owing to a variety of socio-economic, cultural, gender and physiological/biological factors. We carried out a study to assess the extent to which the obstetric needs of the populations in Kitgum and Pader districts in northern Uganda were met during the period 2007-2009.
We collected data retrospectively from Kitgum and Pader districts in northern Uganda during February - March 2010. Data were collected, from three hospitals namely Kitgum, St Joseph and Kalongo covering the period 2007-2009. The data were collected on major obstetric interventions (MOI) which include caesarean section, hysterectormy and laporatomy for absolute maternal indication (AMI) undertaken in the three hospitals. Major obstetric interventions performed for absolute maternal indications (AMI) are critical to saving the lives of both the mother and baby (UON 2011). The data were captured and analysed using Microsoft Excel and SPSS software packages respectively.
Findings A total of 1157 mothers, 527 (45.5%) in Kitgum and 630 54.5% in Pader districts had major obstetrical interventions for absolute maternal indications respectively. The commonest major obstetric interventions for absolute maternal indications were caesarean sections (99.4%) and hysterectomy 0.6% in both districts. The overall deficits in MOI for AMI in Kitgum was (82.6%) 2057 and in Pader (82%) 2667 respectively. In both Kitgum and Pader districts combined, deficits in MOI for AMI performed in urban was (45.1%) 209 versus (85%) 4,438 in rural setting. The main factors contributing to unmet obstetrical needs were lack of qualified health personnel and equipment, and long distance to health facilities.
The study has shown huge unmet obstetric needs amongst the internally displaced populations in the two rural war torn districts of Kitgum and Pader in northern Uganda. Our findings corroborate the high morbidity and crude mortality rates (MoH 2005) and high maternal mortality ratios estimated at 526 in Kitgum and 700 per 100, 000 live births in Pader districts respectively (MoLG 2008) which far exceed the national maternal mortality ratio of 435 per 100, 000 live births (MoH 2011). Previous studies in West Nile districts of Uganda showed that refugees had higher met obstetric needs compared to the host populations (Orach and Debrouwere 2004). The findings draw attention to the poor health status and inequitable access to health services that internally displaced persons often have, that key stakeholders - humanitarian agencies and governments ought to pay attention to.
Furthermore, despite the fact that most internally displaced persons in the districts live in rural settings, we found that the populations in urban settings had better met obstetric needs compared to those living in rural areas indicating large disparities in health status and access to maternal health care services between urban and rural communities. The findings further highlight the need to strengthen health (maternal and child health) services for internally displaced populations in the entire districts as most IDPs live in rural camps scattered cross the districts. In addition, our findings revealed critical areas in the health care system that needs improvement. These include ensuring availability of skilled staff, equipping of health facilities and improvement in temporal, geographic and financial accessibility to health services/facilities. Therefore, the roles of humanitarian agencies - United Nations and non-governmental organizations (NGOs) alongside with the support of local and central governments remain crucial in the delivery of quality and equitable health services for displaced populations.
Ministry of Local Government (MoLG). Kitgum and Pader districts health and development plan 2008.
Ministry of Health (MoH). Health and mortality survey among internally displaced persons in Gulu, Kitgum and Pader districts, Northern Uganda: MoH/WHO study report, 2005.
Ministry of Health (MoH). Uganda health indicators. www.who.int accessed 8th December 2011.
Orach GC, De Brouwere V. Post emergency health services for refugee and host health services in Uganda. The Lancet 2004; 364: 611-612.
Unmet Obstetrical Needs (UON) 2011. Unmet obstetrical needs indicators www.uon accessed on 28th November 2011.
United Nations High Commissioner for Refugees (UNHCR) 2011. Displaced populations under UNHCR. www.unhcr accessed on 2nd December 2011.