Let me tell you a story about Happyness. Happyness is a young woman living in rural Nakaseke district about sixty miles outside Kampala, Uganda’s capital. She just had her second baby who was born premature, and will likely not survive to his fifth birthday. This pregnancy was conceived eight months after her last delivery, though we know that rapid repeat pregnancy, those conceived less than twenty-four months following a delivery, have dire consequences for both mother and baby.
Happyness did not want to become pregnant. Ninety-five percent of Ugandan women are with her on this matter, but her husband believed that family planning would cause infertility or cancer. Unfortunately, these myths are very prevalent and make a real difference. Knowledge is power- and in this case, knowledge is life.
According to the World Health Organization, postpartum women are a priority target for family planning interventions because of the consequences of rapid repeat pregnancy, a fact that is particularly obscured in rural areas. Postpartum women often do not know when their fertility returns or how to use breastfeeding as an effective tool for family planning.
Also according to the World Health Organization, we must use fact-based education and frequent points of contact, and must meet women where they are. If they do not return for postpartum follow-up, then we need to go where they go.
In Vermont, we are doing just that with another vulnerable group: opiate-dependent women. This population is in many ways similar to rural Ugandan women in that they are poor, lack access to healthcare, struggle with food security, and often do not control their fertility. Our Vermont-based program provides myth-busting education through multiple points of contact at a family planning clinic co-located with the local methadone clinic. In a large and ongoing National Institute of Health-sponsored trial, we have significantly increased the uptake and continuation of family planning while decreasing unintended pregnancy. This is a novel, innovative and proven approach. And now we are bringing it to Uganda.
When I started my career in global health, I perceived a need. I knew the statistics. I knew that as a white American woman I had the privilege of safe childbirth, access to contraception, and a supportive partner. I did not, however, fully realize the impact of that privilege. Nothing prepared me for what I saw. In one Ugandan hospital, I witnessed ten maternal deaths in ten days. At the University of Vermont Medical Center, we have had one maternal death in ten years. A Ugandan woman has a one in forty chance of dying during pregnancy or childbirth- a one-hundred-fold risk for her American counterpart. Rapid repeat pregnancy dramatically increases maternal, infant, and child mortality.
Unintended pregnancy is the modifiable risk factor. And family planning is the way to do it.
One of the things I have learned about global health is that you need solid, reliable partners on the ground. You cannot just swoop in. Capacity building on the ground is crucial. If you want a program to work effectively, you need continuity and long-standing partnerships built on mutual trust and support.
This is what we have found in Nakaseke, Uganda with the African Community Center for Social Sustainability (ACCESS), co-founded by Dr. Robert Kalyesubula. This relationship has been built over the years. Dr. Robert was with us here at Yale University, and then returned to Uganda where he works as a skilled clinician, an amazing advocate for his community, and a well-versed researcher and collaborator.
Over the last year, we have worked to adapt our intervention for use in Nakaseke. Through regular Skype calls and in-person visits, UVM and ACCESS teams have puzzled through how to move this project forward so that it makes culturally appropriate sense for rural Ugandan women.
We are now putting these thoughts and plans into action. We are working to be on the ground to pilot this proven effective intervention in a new context. Between the work being done at UVM and at ACCESS in rural Uganda, we have enormous potential to improve the lives of women and families. We look forward to continuing to grow this relationship, and deepening our mutual exchange through this project.
