Kamukama Benic is not a doctor, or even a paramedic. But has considerable experience helping women deliver babies in the eastern Uganda region where he lives and works. Benic drives a boda boda – the East African term for a motorcycle that ferries passengers for cash. Almost every day, his passengers include pregnant women or mothers carrying newborn babies eager to reach the hospital in Ntungamo district.
Health services are uneven throughout Uganda. Some parts of the country have village health teams deployed by the government to help residents. In others, non-government organisations or universities run projects that include community health work. Since public transport is limited and ambulance services are poor, boda bodas are the preferred form of transport for people both in Uganda’s cities and rural areas. Most of the motorcycles that ply on Ugandan roads, including Benic’s, are Indian imports. According to the 2013 Standard Bank Research, 48% of India’s motorcycle exports to Africa in 2012 were bound for Nigeria, followed by Angola and Uganda.
Though boda bodas are not the safest form of travel, especially for pregnant women, they are popular for their efficiency, easy availability and low fares. As such, they have become an intrinsic part of the country’s healthcare system, as even doctors in government health facilities like the clinic in Ntungamo admit.
“Even if someone wants an ambulance, they never get it,” said a health worker who did not wish to be identified. “Either the ambulance is not working or there is no fuel. So people just hop on a boda.”
Used to ferrying pregnant women, boda boda drivers like Benic have come up with a few guidelines for how they conduct their sevice. They make sure a relative accompanies the woman – which means three people ride the motorcycle designed to carry two. This is to ensure the mother-to-be, and the driver too, have some help at hand in the all-too-possible event that the baby comes before they reach the hospital.
“Many times, the woman goes into labour on the motorcycle and we conduct the delivery by the side of the road,” said Benic. “I also help.”
In such instances, the woman gets back on to the motorcycle with her just-born baby, he added. And Benic takes them where she tells him to, driving as carefully as he can.
Fellow boda boda driver Justus Byomuhangi lives in an even more remote area, an island on Lake Bunyonyi in the country’s southwest. He, too, ferries pregnant women to the health facility, an 11-km trip. “If I don’t take them on the motorcycle, they would never reach the hospital,” he said when asked if it was safe for pregnant women to ride pillion.
Not surprisingly, such roadside deliveries often do not end well. Nabirye Amina, 32, went into labour while riding a motorcycle to hospital. “I was just six months pregnant but I knew something was happening, so I got on the motorcycle,” said the mother of four. They did not make it to the hospital and she delivered twins by the road side, with the help of the boda boda driver and some passersby. She was carrying a razor in anticipation of such an emergency and used it to cut the umbilical cords.
Only one twin survived and the driver took the baby to the hospital, leaving Amina on the road with her dead child. Showing the mental and physical stamina that characterises Ugandan women, she carried her baby home to be buried.
Nobody knows if an ambulance ride would have helped Amina deliver both her children safely. But there can be no debate that childbirth in an ambulance would have been much safer.
Pregnant again, Amina is saving up for more motorcycle rides to the hospital for her antenatal visits and for the delivery – resigned to the fact that an ambulance may be too much to hope for. These rides cost anywhere between Rs 80 and Rs 170, depending on the distance.
The poor condition of roads in Uganda makes matters worse, leading to accidents and injuries. Mbabazi Torris, who has seven children and has always traveled to the clinic on boda bodas, once fell off the motorcycle with her child in her lap. “I suffered some bruises,” she said. “But do I have an option?”
The answer is no. There are shared taxis, but these are not as easily available as the motorcycles. And they are expensive – well out of the reach of many women who even struggle to come up with the fare for the boda bodas. “When I don’t have money to pay for the boda boda, I don’t come to the hospital,” Torris said stoically.
Hospital births on the rise
For better or for worse, the boda bodas have become a vital part of Uganda’s healthcare system. So much so that healthcare providers are now experimenting with ways to increase their use so that more women can deliver their babies in hospitals.
As part of one such university study conducted in two districts of eastern Uganda, each mother was given a book of vouchers she could use to pay boda boda drivers every time she needed to visit a health facility. “Facility deliveries jumped from less than 200 to more than 500 per month during the intervention,” said Chrispus Mayora, lecturer and health economist in the School of Public Health, Makerere University Kampala, and one of the authors of the study. “Using locally available resources such as bodas can indeed address challenges of transport in as far as access and utilisation of health services is concerned.”
Mayora conceded that these motorcycles were not the safest way to move patients. But he said, “In settings like ours where we don’t have a functional referral and ambulance system, these bodas are real rescue forces that can be relied upon.” He added, “They need to be better organised and regulated [and trained] on safety standards.”
Twebaze Peace, a midwife at the Rwashawaire IV health facility, also said deliveries in the hospital have increased because women are now saving money for boda boda rides to the facility. “How can anyone expect a pregnant woman to walk to hospital while she is in labour?” she asked as she attended to Ekiyansiimire Yudaya, who was in labour.
Not surprisingly, Yudaya had come to the hospital on a boda boda.
All photographs courtesy Priyanka Vora.