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Author: Simon Mugudde
Adolescent Girl’s Triumph Story
Resilient Rise from Adversity of Teenage Pregnancy!
“If every underage girl exposes what grown men say and do to them, you would immediately lose respect for most men, including many of those camouflaged-uncles, seemingly-harmless-clerics, and educated-men wearing expensive suits” – Amina
Simon Mugudde – MAKEXAFRICA: By the time of this interview, Amina was met at her grandfather’s house that afternoon to advise him on how to solve a land wrangle with his neighbours, since she had acquired a certificate in legal practice. “My father’s plan for me was that I would go to Saudi Arabia after my PLE. This is something I hated with all my heart. But my father had met a man from Saudi Arabia with whom he negotiated to connect me to “better opportunities” in Saudi Arabia. To prepare me for this journey, I had to learn Arabic. I already knew a bit of Arabic from the language program at our local mosque. To perfect my skills in speaking Arabic, my father hired a teacher of Arabic. Umar used to come to my father’s house to teach me Arabic. I spend every Friday and Saturday evening of primary seven with Umar, sometimes in my father’s living room, or under acacia trees on his compound. I was less interested in skilling in Arabic. My interest was to pursue further education, probably up to university level. I remember two girls on our village who used to wear t-shirts written on ‘Makerere University’ in large letters. I fantasized about studying in Makerere University. My father had such trust in Umar to the point that he was the only man he would allow have access to me. As I neared sitting for my PLE, I could hold a modest conversation in Arabic. Umar had done a good job. That was not all. Umar made me so comfortable around him to a point where I could feel annoyed if he never showed up to teach me Arabic. After my PLE exams, my father started processing ‘papers’ for me to travel, with the help of the man in Saudi Arabia. Before my PLE results were out, I got results from my comprehensive health check. My father beat me up so bad, into a stupa! On the living room floor that night I could hear my mother begging with my father, ‘stop it please – you are going to kill her’. My body went into a painful-trounce, I stopped feeling my father’s lashes. I blacked-out. The morning after, my father instructed my mother to let me know that he was going out into the fields to work, but he did not want to find me at home when he returned. With the help of my mother, I made it safely to a distant relative of mine in Namisambya in Kamuli district. Carrying the remaining seven months of my pregnancy was hell-on-earth, as a naïve thirteen-year-old. My living conditions were pathetic. My caretaker relative lived off of a tiny piece of land in a little grass-thatched-mud-and-wattle house, growing crops for food and rearing a few chickens. The pregnancy test-scan had indicated that I was carrying twin-boys. The weight of my pregnancy overwhelmed by tiny thirteen-fourteen-year-old body. With poor feeding, and almost no access to antenatal care, I got weak, weaker, and sick! I gave birth to two-underweight-boys who looked exactly like Umar. All this long I had not heard from anyone in my family, except one day when I received a verbal message from my mother through someone who visited Namisambya. At the village maternity where I gave birth were three white girls who had come to the local health facility for medical practice. One of the girls got so interested in me and my babies, and ensuring that my wound from the C-section was healing as expected. Everything from learning Arabic, to sitting for my PLE, to getting pregnant and carrying a pregnancy, to giving birth by C-section, happened so overwhelmingly quickly. And just like that, my life had taken a U-turn. Sometimes I broke down and cried really hard. I regretted everything. I blamed Umar for making me pregnant. I blamed Umar for not looking for me when I left home (I also did not want to see Umar, ever again). I blamed my father for throwing me out of his house. I blamed my father for bringing Umar to our house. I blamed my mother for something I did not know how to articulate. Entangled in blaming everyone and everything, the realities of my situation started twinkling in, and hitting me hard. My distant relative could not afford to take care of me. Her own pregnancy had grown. Her food stock was depleting. My babies needed milk more that my breasts could produce. I could not afford diapers or warm-clothing for my babies. Mosquitoes were relentless on us. I was pushed to the lowest limit. I regreted everything. At the local health facility where I had gone for malaria treatment for myself and one of my twins, was a girl who had given birth two months earlier than me. It was her second child. She looked younger than me. We started talking. I could visit her home. She could visit me. My conversations with her felt like calm downpours on a withering plant. Over the months I had accumulated steam trapped within me. Her name was Bilabwa. The white girl who was interested in my health and that of my babies ended up staying – living longer in Uganda. She accepted me in her house. Natalie connected me to support for my babies but on condition that I was willing to go back to school. She helped me trace my PLE results. I had scored aggregate 13 – a super-B. While my score was not a first-grade score, it was the best my school got in my year. Natalie was proud me for being the best student in my class. I was happy. I enrolled in a secondary school in Acholi in Northern Uganda where Natalie worked at a health facility. Many things happened during my education. My babies grew up. Natalie got married to a man from Acholi. I enrolled for a course in legal practice. I am now 27 years old, skilled, employed, focused, healthy, and optimistic about the future, as a professional and a mother of twin boys. With resilience, I rose out of my predicament but not every girl who experiences underage pregnancy rises out of it. Some are emotionally hurt beyond repair. Some are left with incurable infections. Some suffer Post-Partum-Haemorrhage. Some suffer life-threatening abortions. Some are disowned. And some pay with their lives. My message to anyone trying to protect girls from getting pregnant is that, instead of giving endless lectures to girls, parents put in your homes serious restrictions preventing your girls from having access to men, or any environment that would compromise them. You cannot control an adolescent girl’s hormones with lectures and scripture verses, but tough barriers on who they have access to at home, in school, at church, at the mosques, anywhere. The reason I got pregnant at 13 was not because my parents did not talk to me about not getting pregnant. It was not because I didn’t know what the Quran says. It was not because I did not know the value of education. It was because I had access to a man in my father’s house, and I could only control my teenage hormones sometimes, not all the time. Parents who can afford, please provide your girls with access to entertaining physical activities, especially sports. The more I sat idle in my father’s house, the more I thought about Umar. I had unreleased hormonal energy trapped inside of me. The unreleased hormonal energy in me overpowered my fear of consequences. Let the law enforcers arrest and imprison the men who impregnate underage girls. Why should a man be known on his village for impregnating underage girls but he still roams freely on that village, even runs for elective politics? There are many, many men who wake up in Uganda every morning and the most important thing on their mind is to find an underage girl to sleep with. They prefer the underage girls because they are ‘affordable’, and do not ‘disturb’ them. In a way, due to the women empowerment programs, the older girls/women are more independent minded, assertive, as well as ‘expensive’, making it hard for most men to hoodwink them into quick sex. That is why they prefer underage girls who are still naïve. But what message are we sending to our girls, that it is okay for men to prey on them? If men impregnating girls cannot be arrested why should girls see it as wrong to go out with them? What is so annoying is that the very men supposed to be arresting men preying on underage girls, are also preying on underage girls! It is such ‘grown’ men who go around asking, “what is wrong with children of these days”? Well, how about we start asking, “what is wrong with elders of these days”? do you remember, a few years ago, when a government minister said that if girls who dress skimpily are sexually abused, they have no one else to blame but themselves? Let me tell you something; over the years I have realized that it is not so much about provocative dressing that will compel men to lure a girl into sex. Men, in my observation, will have intentions of sex even with a scarecrow dressed as a woman, with breasts and bums. Mothers, protect your girls the way a hen protects her chicks from preying eagles! In my opinion, the increasing teenage pregnancy in Uganda, with limited action to curtail it, is a sign of our collective hypocrisy as a country! If every underage girl exposes what grown men say and do to them, you would immediately lose respect for most men, including many of those camouflaged-uncles, seemingly-harmless-clerics, and educated-men wearing expensive suits. I will try the best I can to raise my twin-boys into men who value and respect women, men who will not prey on underage girls” – AMINA
Malaria in Adolescent Girls
MALARIA IN UGANDA
Simon Mugudde, MAKEXAFRICA – JINJA – Uganda has made great progress in reducing malaria transmission from 42% in 2009 to 9% in 2018. Despite this, in 2021 Uganda had the 3rd highest global burden of malaria cases at 5.1% and the 7th highest level of deaths at 3.2%. It also had the highest proportion of malaria cases in East and Southern Africa of 23 % in 2021. The CDC says that young children and pregnant women are the most vulnerable to malaria because they have not yet developed immunity to malaria, and pregnancy decreases a woman’s immunity. Between 2020 and 2021, the estimated number of malaria cases remained stable at 284 per 1000 of the population at risk, while deaths fell 6.1% from 0.46 to 0.43 per 1000 of the population at risk over the same period. There is stable, perennial malaria transmission in 95% of the country, with Anopheles gambiae s.l. and Anopheles funestus the most common malaria vectors. Plasmodium falciparum accounts for 98% of infections; both P. vivax and P. ovale are rare and do not exceed 2% of malaria cases in the country. Uganda experiences two malaria transmission types: Stable, perennial malaria transmission which exists in 90–95 % of the country, and the low and unstable transmission with potential for epidemics in 5-10% of the country. Transmission peaks are aligned with the two annual rainy seasons, which take place from March to May and from September to November. Although the entire population is at various levels of risk, marginalized populations are confronted with economic, social and contextual challenges and barriers that may limit their access to malaria prevention, treatment and control programs, including children under five years and pregnant women as most vulnerable and under-served populations. Gender-based disparities and social customs have created hurdles for accessing malaria related services. A key example of this is that health seeking decisions are often taken by male family heads of family and this could lead to delays in practicing preventive measures or seeking treatment.
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Women Entrepreneurship
SOCIAL-ECONOMIC SITUATION
Simon Mugudde – MAKEXAFRICA – Jinja Uganda: Busoga region comprises the 12 districts of Iganga, Jinja, Buyende, Luuka, Kamuli, Kaliro, Namutumba, Mayuge, Bugiri, Namayingo, Buvuma, and Bugweri comprising 73 Sub-Counties, 571 parishes, and 5659 villages – making up Busoga region. Busoga has the second largest regional population share of 9.7% of Uganda’s 48,582,334 people (only second Buganda region with 11.5%). UBOS (2021) observes that, “there is high population density in Busoga but with low levels of economic activity”. Poverty as major catalyst, has many consequences on Busoga, one of which is teenage pregnancy (2016 UDHS). Approximately, 33.5% of teenagers in the poorest households in Busoga were reported to begin childbearing, compared with only 15.1% in wealthy households (UBOS, 2021).
Uganda National Household Survey (UNHS) 2016/17 reported as high as 14.5% the rate of poverty in Busoga, followed by Bukedi at 10.4% and Acholi at 10.3%. Out of the 8.3 million people believed to be below the poverty line in Uganda, 1.162 million people are in Busoga sub region. Approximately, 14% of all poor people in Uganda are in Busoga. UBOS (2020) ranked Busoga the poorest region in Uganda, attributing it to “poor population planning”. Poverty in Busoga increased from 8 million poor people in 2016/2017 to 8.3 million people in 2019/2020, indicting a 22% increase.
Compared to other regions of Uganda, the dependency ratio in Busoga is worryingly high. For instance, according to UBOS (2019) between 2012 and 2020 Busoga’s dependency ratio averaged at 114, which is higher than Buganda’s 88, Elgon’s 69, and Kampala’s 54. The worrying dependency ratio in Busoga is precipitated by the fact that the majority of the population lies in the 0-14 years age bracket (the dependency bracket). Further, many of the adults in the working age bracket of 15-64 years of age, are actually non-productive dependants. Moreover, there are also many people in the category aged above 65 years of age, who are complete dependants.
Approximately 29% of households in Busoga are headed by women, compared to 31.1% in Buganda, 36.6% in Kampala, 26.5% in Teso, 64.7% in Karamoja, and an average 31% across Uganda. Approximately, 11% of marriages in Busoga are polygamous, compared to only 2.6% in Kigezi, 7.6% in Buganda, 4.7% in Lango, 5.9% in Tooro, and 3.2% in Kampala. Polygamy is one of the fronted precipitator of poor health at household level, especially malnutrition, indicating that polygamous families are more likely to not afford enough nutritious food, given the large numbers of household(s) members.
For the period 2020-2021, overall literacy of persons aged 10 years and above in Busoga averaged at 67.4% compared to Kampala’s 93%, Buganda’s 83.5%, West Nile 75.2%, Bukedi’s 59.6%, and Kigezi’s 78.3%. Busoga’s literacy levels are not far different from the rest of the regions in Uganda, so why is the region consistently registering poor indicators, especially in health. More specifically, for instance, UBOS (2019/2020) reported that different parts of Busoga register different levels of literacy. In Bugiri literacy levels are at 39.8%, in Namayingo 17.7%, in Mayuge 39.6%, in Iganga 31.6%, in Kamuli 31.4%. According to the Uganda National Household Survey (2020), surprisingly, between 2018 and 2021, an approximated total of 41% of children between 3 and 5 years of age were in school, higher than Kampala’s 34.5%, and Kigezi’s 37.2%. Primary school enrollment in Busoga in 2020-2021 was averaged at 83%, compared to Kampala’s 87.3%, Bukedi’s 82.5%, Karamoja’s 43%, and Buganda’s 87%. Secondary school enrollment in Busoga in the same period was averaged at 33.9%, compared to Kampala’s 50.4%, Teso’s 7.7%, Lango’s 16.2%, and Ankole’s 28.7%. Questions still linger about why, with the high early enrollment in school, there is such a low school retention rate in Busoga.
According to the 2023 Uganda Demographic Health Survey, Busoga has one of the highest fertility rates at 5.7%, only second to Karamoja which is at 6.7%. Busoga also has one of the highest infant mortality rates, at 41.4 (for every 1,000 live births), compared to Teso’s 21.1 and Karamoja’s 26.1. For under 5 mortality, Busoga registers 65.1 (for every 1,000 lives births), the second highest in Uganda after West Nile’s 79.5. In 2021 KOICA reported a Uganda national maternal mortality rate of 336 compared to a 448 rate in Busoga region (for every 100,000 live births).
The national Sickle Cell Trait prevalence in Uganda stood at 13.3%, while in Busoga it was at 20%, according to a LANCET Global Health Study in 2017. Since 29% of the blood donated in Uganda is used to treat people with severe malaria and 17% to treat people with Sickle Cell Disease, and yet Busoga region has the highest prevalence of malaria and Sickle Cell Disease in Uganda, the need for establishment of a blood bank in Busoga is a matter of life and death. Further, while the average national prevalence of malaria in Uganda is 9%, Busoga has a prevalence rate of 21%.
The Uganda Demographic Health Survey (UDHS) 2022 shows that teenage pregnancy across Uganda regions, varies largely. Since 2011 the highest teenage pregnancy rates, have consistently, been reported in East-Central Uganda, registering 30.6% in Busoga, and this figure growing to 36.3% among 15–19-year-olds in 2021. As far as taking initiative to seek medical treatment, UBOS found out in 2021 that 33.7% of people in Busoga were reluctant to seek medical treatment because they though their illness was mild, while 30.6% indicated a lack of funds for medical consultations. Compared to other regions of Uganda, including Bukedi, Elgon, Teso, Karamoja, Lango, Acholi, West Nile, Bunyoro, Tooro, Ankole, and Kigezi, it was only Busoga with the highest percentage of people failing to seek medical attention because they could not afford medical costs. Approximated 83.8% of people in Busoga move a distance of up to 3 Kilometers to the nearest health center, while 5.2% moved a distance of over 8 kilometers. The distance to the nearest health center in Busoga is shorter than in some regions of Uganda but the willingness to seek treatment in other regions is higher than that in Busoga.
Bleeding Adolescent Girls
Girls and Women Endangered by Premature Births and Post-Partum Hemorrhage in Uganda
Simon Mugudde – MAKEXAFRICA – Jinja: Uganda has a high rate of preterm births, with 14% of babies being born before 37 weeks, and 13.6 per 1,000 live births. Preterm births are the leading cause of neonatal deaths, accounting for 28–31% of all neonatal deaths, and are directly responsible for 8/27 neonatal deaths per 1,000 live births. Approximately, 226,000 babies are born preterm each year, with 11,000 born before 28 weeks, and 5,700 impaired survivors.
Iron deficiency is the most common cause of anemia during pregnancy in Uganda, and is a risk factor for premature birth and infant mortality. In low- and middle-income countries, maternal anemia is responsible for 12% of low birth weight, 19% of preterm birth, and 18% of perinatal mortality. Other risk factors for anemia include: intestinal parasites and unprotected drinking water. Moderate and severe anemia can also be associated with maternal HIV infection, maternal blood transfusion, neonatal death, and decreased placental thickness. Red blood cell (RBC) transfusions are a key treatment for anemia of prematurity. RBCs stored for up to 42 days since donation are safe and effective for small volume transfusions. Other risk factors for premature births in Uganda include high rates of malaria transmission and adolescent births.
Post-Partum Hemorrhage (PPH) is the leading cause of maternal deaths in Uganda, accounting for 35% of all maternal deaths in the country, with an incidence of 9%. The soon-to-be released Uganda Clinical Guidelines, 2022, and the Essential Maternal and Newborn Clinical Care Guidelines, 2022, recommend Heat Stable Carbetocin (HSC), oxytocin or misoprostol for the prevention of PPH and oxytocin or Tranexamic Acid (TXA) for its management. One in three women have anemia in pregnancy. Risk of PPH when anemic is 50%. PPH Case fatality 2.3%, and PPH is responsible for 34% of all maternal deaths reviewed. Hemorrhage was the leading cause of death across all levels of health care with the biggest contribution at health center II and III levels.
Tranexamic acid is also included in the Essential Medicines and Health Supplies List for Uganda (EMHSLU) 2016. In Uganda, tranexamic acid is available as Transamin injection, Transamin 250 and 500mg tablets, Hemsamic 500mg tablets, Tranlok 500mg tablets and Tranlok injection. Tranexamic acid offers an additional benefit above and beyond what is being done for women already. Further, uterotonics, including oxytocin, are widely used in Uganda. In lower-level health facilities in Central Uganda, 97.4% of women received a uterotonic for the prevention of PPH, with oxytocin being most commonly used. Oxytocin is also widely available in the Ugandan public health sector, with 90% of public health facilities reporting its availability. However, the availability falls below the World Health Organization benchmark of 80% in private health facilities (52%) and non-government organizations (NGO) or faith-based institutions (63%). Similarly, while misoprostol is 88% available in public health facilities, it is only 50% and 55% available in private and NGO/faith-based facilities. Private medicine outlets, including pharmacies and drug shops, play a critical role in plugging such gaps in the public health supply chain. However, a study done in private medicine outlets across four districts in Uganda found oxytocin to be available in only 37% of the private outlets.
The Uganda National Drug Authority (NDA) drug register indicates that over ten brands of TXA and two brands of HSC are registered for use in the private sector in Uganda. Key players in the private sector include private importers and wholesale pharmacies, clinics and private hospitals. Procurement and distribution of medicines and supplies in public health facilities is handled by the National Medical Stores (NMS). Engagements with the MOH and the NMS indicate that plans for procurement of HSC and TXA for use in the public sector for financial year 2023-2024 are underway with support from the Government of Uganda and the United Nations Population Fund.