Quiet heroes of childbirth

In October 2007 the Guardian and Observer embarked on a three-year project to support work carried out by Amref and Farm-Africa to improve the lives of people living in Katine, Uganda. The project is being funded by donations from readers and Barclays. This year's Guardian Christmas appeal focuses on the lives of women Sarah Boseley

Women don't die in childbirth in Katine, they will tell you. It's true. They die in Soroti hospital, eight and a half miles away, or on the journey there. Katine, a rural sub-county of north-east Uganda, which the Guardian is supporting, has no doctor who can do caesareans or otherwise deal with complications. All the hard cases must go to the referral hospital. When they arrive, perhaps semi-conscious, in agony and suffering from blood loss, it can be too late.

Soroti hospital's maternity ward is silent and dark, with listless bodies. It's not a joyous place. The beds have been pushed close together to fit more in, but all of them are taken. Some women with drips in their arms lie on the floor.

Caesareans take place daily. Some months no women die; more commonly, there are one or two deaths, and sometimes as many as five. The death rate in 2006 was 196 women per 100,000 births. In the UK, it is around eight.

There is a simple reason for this, says Godfrey Egwau, the obstetrician and acting medical superintendent. Neither Katine nor any other sub-county region around Soroti has a doctor. Like Katine, they have a level 4 health centre, equipped with wards and an operating theatre. But nobody is qualified to do lifesaving surgery. "One [woman] died last night," he says. "She had a ruptured uterus. We couldn't save her.

"It is an issue of human resources. What we need is not in this hospital - I mean doctors. The issue is pay. The government pays them 450,000 shillings (£155) a year, but if they work for an NGO, they are paid 1.5m shillings."

As a result, much of the Tiriri health centre in Katine is empty and idle. In any case, its operating theatre and resuscitation apparatus and sterilisers are rendered redundant by the absence of electricity. Cables torn down by the invading Lord's Resistance Army in 2003 have never been replaced. A year ago there was a doctor, but he rarely set foot in the place. Now he has a job in a major city hospital. A year ago there was an ambulance under a mango tree. Now it is at Soroti hospital, because there is no doctor to demand it stays and manage the budget to pay for maintenance.

Routine deliveries take place all the time. The midwives work hard and well. There are always a few new babies in the maternity ward. Antenatal clinics take place every morning. Last year 1,278 births were registered here, although many will have been born at home with the help of a traditional birth attendant (TBA), and brought in for a check-up.

Horrible journey

Anna Grace Amaso, who cannot remember how old she is, is waiting to go home after the birth of her fifth baby, a girl, a few hours earlier. "I was brought by my husband on the back of the bicycle," she said. It was midnight, she was in labour and it was pouring with rain. She sat on the bike and he pushed her through the mud. "It was a horrible journey. We went to check on the TBA, but she was not around, so we came here."

Women go to TBAs, the quiet heroes of childbirth, because they are nearby and will help in exchange for, at most, a chicken, whereas the health centre charges mothers 4,100 shillings (£1.40) for a black plastic sheet and sterile gloves, and 200 more for paraffin for the lamp - a significant sum for them.

The TBAs, many of them elderly women who have helped scores of babies into the world, have no equipment or drugs. They cannot do a forceps delivery, or stitch a tear. But they do just fine in a normal delivery.

The African Medical and Research Foundation (Amref), which is running the development project in Katine, funded by donations from Guardian readers and Barclays, ran a five-day training course for 19 TBAs, which impressed upon them the circumstances under which they must refer a woman to the health centre.

Josephine Achen, who thinks she is about 70, has delivered 30 babies since March. After every delivery she personally takes the woman to Tiriri for a check-up and for the baby to have immediate immunisation. It is six or seven miles away. Her biggest need now, she says, is a bicycle. "It would simplify our work," she says. Amref plans to supply bicycles to some TBAs.

But no amount of training can prepare a traditional birth attendant to anticipate every complication. When things go really wrong, a borrowed bicycle will help a husband get to the health centre for help, but all that the midwives in the maternity unit can do is radio for the ambulance in Soroti. It is not well-maintained and there are questions over its battery and tyres. It will take the woman only if her family can pay 70,000 shillings (£22) up front for fuel. In the time it takes to raise the money from friends and family, the woman can have a ruptured uterus and arrive in Soroti hospital bleeding to death.

One answer, which Amref is promoting to the Ugandan government in Kampala, is for midwives and clinical officers (who have a couple of years' medical education) to be trained and authorised to carry out emergency caesareans. In the meantime, for many women, the best hope is a trained TBA and a bicycle.