BIDI BIDI, Uganda – Under a tarpaulin tent pitched in the world’s largest refugee settlement, a pair of newborn twins is cause for celebration. “They will grow fat,” midwife Christine Ajidiru says, gushing over the mother, Maria Gire, who is breastfeeding one of her new baby girls.
The tent houses the maternal and child health unit of Koro health center in Bidi Bidi camp – a sprawling refugee camp in northern Uganda that has rapidly grown into the world’s largest over the past year, as conflict rages in nearby South Sudan.
Gire’s husband, with whom she had her first four children, was killed in 2013 in fighting in South Sudan. After her husband’s death, she was “inherited” by his brother, a customary practice in which the closest male relative to the deceased performs the duties of a husband after a woman is widowed.
Gire, now 30, fled over the border into Uganda on foot with her husband’s brother and her children in September 2016. Not knowing about family planning, she became pregnant by her brother-in-law one month after arriving at Bidi Bidi.
In the lead-up to her delivery, Gire attended checkups alone. Her brother-in-law lives with his other wives in Imvepi settlement, about 27 miles (45km) away, while Gire lives with her children and a “co-wife” of her late husband.
When the time came to give birth, Gire did something many women would consider unthinkable: she walked over a mile to the health center from the grass thatched hut she built for herself in Bidi Bidi.
One in five women of childbearing age in crisis situations are likely to be pregnant, according to the United Nations Population Fund (UNFPA). Pregnant and lactating women are also some of the worst affected by conflict.
Without access to proper maternity care and reproductive health services, women who have escaped horrific situations at home face an increased risk of life-threatening complications to their pregnancy.
Uganda has been lauded for its generous policies toward refugees, which include free healthcare. But with the country now hosting 1.2 million refugees from 13 countries, the bulk of them women and children from South Sudan, resources are being stretched to the limit.
UNICEF found that a total 23,680 children were born to refugees in Uganda between January and November 2016. In Bidi Bidi alone, 1,153 babies were born between August 2016 and May 2017.
Obstacles to providing adequate maternal care in the country’s 10 refugee settlements include limited transport, poor roads, bad phone networks and stigma about family planning.
Busy Clinics in a Vast Camp
Bidi Bidi is current home to some 270,000 refugees and continues to grow as bloodshed continues over the border in the young nation of South Sudan. There are 11 health facilities in the settlement, including two government facilities which have basic maternal and obstetric care services.
The International Rescue Committee (IRC), supported by the U.N. refugee agency, has introduced a comprehensive health program in two zones of Bidi Bidi. The Koro health center is one of three health centers in its zone, which is home to 48,000 refugees. Last month at the Koro health center, which has a total 23 beds across nine rooms – eight of them dedicated to maternity and child health – there were 43 vaginal deliveries.
As well as delivering babies, the center also offers outpatient department consultations, family planning and immunization services, and has a nutrition program. It also houses a “breast-feeding corner,” with posters nailed to the plastic tarpaulin structure showing new mothers the different ways to breast-feed.
Yet there is only one ambulance per zone, said Ramula Munduru, a reproductive health officer with IRC in the town of Yumbe, about 10 miles away from the Koro zone.
“All mothers are referred to Yumbe Hospital for blood transfusions, services we cannot offer in [IRC] health facilities,” she said, adding if there’s no blood there, the patient will have to be transferred onto Arua, about 55 miles away. “That leaves the whole zone without an ambulance.”
Infrastructure is another major problem. “The bridge going to Swinga Health Center 3 [in the same zone as Koro] is broken and the community cannot cross it when the river is full,” she said.
Sometimes, the windy weather knocks down the tarpaulins in Koro. “If they’re blown off, we cannot offer services in that room, so we have to transfer patients to another, which becomes a bit difficult,” Munduru said. “Supplies also sometimes get destroyed.”
Ugandans who live nearby use the Koro health center, as well. In the first week of July, 478 people have been attended to in the outpatient department, 450 of them refugees and 28 of them Ugandans. When Ugandans come to the center this adds extra pressure, although Ajidiru said most nationals are seeking prenatal care, and do not give birth at the center.
Low Mortality Rate
Despite the barriers to maternal care, since the Koro health center opened last September, there has been only one childbirth-related death, in a country where 16 women die of maternal mortality daily.
“It’s not because there’s a lot of staff,” Ajidiru said. “Sometimes when there are many women, we have the challenge of two or three mothers delivering and there’s only one midwife.”
“It’s because the staff are very knowledgeable and they act very fast,” she said.
IRC has stressed that not only have many women fled a country mired in conflict, they have also left poor reproductive health services which could have cost them their lives if they had stayed. South Sudan has the world’s fifth-highest rate of maternal mortality. There has only been one case of fistula in Koro, which staff attribute to the mother having had home births in South Sudan.
“When you deliver at home in South Sudan, you bleed a lot,” said Gire, who gave birth at home three times with a traditional birth attendant. At Koro, “I was injected with a drug that controls bleeding.”
Although Ajidiru says Koro lacks “good sanitary places for the mothers to bathe in,” Gire said she was cleaned by a midwife and given a “divinity kit,” containing a baby shawl, a kitenge (sarong), slippers, soap and panties.
In another zone of Bidi Bidi, Betty Juan, 18, who fled South Sudan in May 2016 with her two children, gave birth in a health center operated by Medecins Sans Frontieres (MSF) in early July. When she fled South Sudan, leaving her husband behind, she was one month pregnant.
“In South Sudan the labor pain can take long, but this time it didn’t,” she said.
From February to May this year, MSF admitted 222 women for maternal care, assisting with 111 births. The main reasons for admissions other than delivery were malaria during pregnancy.
MSF also works in other three other refugee settlements in Uganda. Aid groups say the level of healthcare is quite similar across the settlements, but infrastructure varies depending on how old the camp is.
In Bidi Bidi, besides a high rate of malaria among pregnant women, midwife Gloria Endreo said one challenge was the poor phone connection.
“Women call the phones but the phones are off and they cannot reach us so eventually they end up delivering at home,” she said.
But Juan is happy with the care received at the center.
“I was so scared in South Sudan,” she said of her pregnancy. ”But when I reached Uganda, I stopped fearing.”
This story has been updated to correct the agency funding the IRC’s comprehensive health program in Bidi Bidi. It is the U.N. refugee agency, not the U.N. Population Fund.