1. Maternal and Reproductive Health Issues in Uganda Miriam Nakalembe, MD OB/GYN, Makerere University, Kampala, Uganda Global Health Lecture Series, Lubbock, Texas (November 19, 2012)

2. Outline UGANDA MATERNAL HEALTH STATUS CERVICAL CANCER COLLABORATIONS 2 Global Health Lecture Series, Lubbock, Texas

3. Uganda Basic Facts – Area: 236,040 Sq Km (1/3) – Population: 35M (10M>) – Ranking: 154/177 countries – Life expectancy 52.7yrs – 80% rural, Agric – Per capita income 453 USD 3 (UBOS:www.ubos.org ) Global Health Lecture Series, Lubbock, Texas

4. Uganda Landscape 4 Global Health Lecture Series, Lubbock, Texas

5. Uganda Selected Health indicators 1991-2012 5 Global Health Lecture Series, Lubbock, Texas Indicator YEAR 19911995200220072011 CPR514.922.823.730 TFR7.16.9 6.76.2 MMR527506505435438 Adolescent pregnancy (%)4443322515 IMR (/1000)12281857661.2 HIV prevalence rate30156.16.46.7 Supervised deliveries (%)38 4158

6. Uganda Trends in Contraceptive use (%) 6 Global Health Lecture Series, Lubbock, Texas

7. Uganda Trends in Births in a Health Facility 7 Global Health Lecture Series, Lubbock, Texas

8. Maternal Health Status Magnitude of the problem – Globally 385,000 women die - Pregnancy related complications – > 90% in low resource countries e.g. Uganda – For every death, 20-30 suffer morbidity – Causes are known/ largely preventable 8 Global Health Lecture Series, Lubbock, Texas

9. Maternal Health Status Causes on maternal mortality 9 Global Health Lecture Series, Lubbock, Texas CAUSE OF DEATHSPERCENT Haemorrhage (Bleeding)26% Sepsis (Infections)22% Obstructed Labour13% Unsafe Abortion8% High Blood Pressure (Pre-eclampsia & Eclampsia)6% Other Causes (e.g. Malaria, HIV etc)25%

10. Maternal Health Status Maternal deaths are closely linked to delays in accessing care – The 3-Delay model Delay at home Home to Health unit At Health unit 10 Global Health Lecture Series, Lubbock, Texas

11. Maternal Health Status 1st Delay – Occurs within the household/family level – Limited ability of the woman and relatives to make a decision to seek care. – Linked to the inability to appreciate danger signs of pregnancy 11 Global Health Lecture Series, Lubbock, Texas – Cultural practices restrict women from seeking health care – Poverty at the household

12. Maternal Health Status 2nd Delay – Inability to access available health facilities when need arises. – Lack of timely means of transport 12 Global Health Lecture Series, Lubbock, Texas – Long distances to health facilities, poor roads and communication. – More than 38% of the population lives below the poverty line.

13. Maternal Health Status 3rd delay – The functioning health centre or hospital is a critical factor in reducing the life-threatening delays and the subsequent prevention of maternal death and disability. 13 Global Health Lecture Series, Lubbock, Texas

14. Maternal Health Status Underlying Issues – Individual Total Fertility Rate (experience) Awareness and poverty levels – Government level Nurse Population Ratio: 0.16/1000 Doctor Population ratio: 0.05/1000 – Road and communication infrastructural – Shortages of equipment, supplies & their management – Funding priorities – Gaps in monitoring and evaluation 14 Global Health Lecture Series, Lubbock, Texas

15. Maternal Health Status Maternal mortality is a massive problem – which ever way you look at it!!! – Where do we start? – What roles would you play to impact on this problem? 15 Global Health Lecture Series, Lubbock, Texas

16. 16 Efforts Government – Poverty alleviation programs – Increase Human resource capacity-hard areas – Equip Health Units – On Job training in Emergency Obstetric care Association of OB/GYN Not for profit initiatives e.g save the mothers initiative Global Health Lecture Series, Lubbock, Texas

17. National Referral Hospital Aerial view 17 Global Health Lecture Series, Lubbock, Texas

18. National Referral Hospital Upper Hospital 18 Global Health Lecture Series, Lubbock, Texas

19. OB/GYN DEPT 1500 beds Annual in-patient turnover >140,000 OBS/GYN-Labor ward (high risk & low risk) – 33,000 deliveries/yr – Over 100 admissions/day – Average 20 Emergency C/s – 10-15 complicated labors/day 19 Global Health Lecture Series, Lubbock, Texas

20. Discussions End of Maternal Health overview Global Health Lecture Series, Lubbock, Texas

21. Cervical Cancer - World Wide Burden 21 FerlayJ, et al.GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide. IARC CancerBaseNo.10. Lyon, France. 2010 Every 2 minutes a woman dies of cervical cancer. 1 Every minute a woman is diagnosed with cervical cancer. 1 New cases per year: ~ 530,000 Deaths per year: ~ 275,000 NA + Europe Asia Latina 29,000 31,000 159,000 77,000 Africa 53,000 80,000 68,000 312,000 80% in developing countries = 2nd cause of cancer death in women Global Health Lecture Series, Lubbock, Texas Cervical Cancer

22. Cervical Cancer – Uganda Stats Uganda incidence 45.6/100,000 It is the leading cause of gyne deaths (70% at Mulago Hospital) Almost all cases are advanced Facilities to screen and treat are limited Skills to diagnose are limited 5% of women ever get access 22 Global Health Lecture Series, Lubbock, Texas

23. Cervical Cancer - Screening options Main stay of prevention (Primary & Secondary) Screening options – Pap smear – Visual inspection of cervix with 5% acetic acid/lugol’s iodine Treatment of pre-cancer (cryotherapy, LEEP) Experience 23 Global Health Lecture Series, Lubbock, Texas

24. Cervical Cancer - Barriers to cervical cancer screening Commitment – Lack of enabling policies & evidence based guidelines As a consequence -no resources for Cervical & other cancer control programs Competing priorities? HIV, TB, Malaria? Inadequate advocacy – limited data on burden Inability to scale up & sustain pilot screening 24 Global Health Lecture Series, Lubbock, Texas

25. Current interventions-Strategic plan Public education and advocacy Prevention of Human Papilloma Virus (HPV) infection (primary prevention) Screening and treatment of cervical precancerous lesions (secondary prevention) Treatment of cervical cancer Palliative care for cervical cancer Programme monitoring and evaluation 25 Global Health Lecture Series, Lubbock, Texas

26. Collaborations Centers of excellence – PMTCT-HIV & Peadiatric HIV Baylor College of Medicine Bristol Myers Squibb Children’s Clinical Centre of Excellence Makerere-University-The John Hopkins Research Collaborations/Grant writing International staff & student Exchange program (Yale, BC, London School etc) 26 Global Health Lecture Series, Lubbock, Texas

27. END DISCUSSIONS Global Health Lecture Series, Lubbock, Texas