MESSAGE
Reproductive health services for WWDs can be improved by making them disability friendly.

PRIMARY TARGET
Midwives and Doctors in a district setting in Uganda.

Introduction
Uganda’s maternal mortality rate of 500/100,000 is the highest in East Africa. Steps have been taken to improve reproductive health (RH) services to make them more responsive to the needs of women in Uganda. However, these initiatives have not taken into consideration the needs of Women with Disabilities (WWDs). Consequently, WWDs often chosen to use traditional birth attendants, who offer more disability-friendly services, although these may not be as safe as those offered in formal health units. Simple and inexpensive innovations such as improving access to buildings, better means of communication and empathetic RH providers, along with current improvements that target all women will make RH services more disability-friendly. This article describes the special needs of WWDs and suggests innovations to improve services for them, which can be implemented by various RH providers in the district.

The Unique Needs Of Women With Disabilities
WWDs have unique needs that require special approaches in health service delivery. These needs arise from the women’s impairments, society’s frequently negative response to the impairments and the women’s reactions to both the impairment and society’s attitude to them. These responses, which feed into each other, often result in WWDs with low self-confidence. This limits their ability to negotiate for quality services. In addition to this, many WWDs who seek RH services have suffered neglect or have been abandoned by their spouses or family. Poverty, which is prevalent among people with disabilities (PWDs), further compounds the disabled woman’s dilemma. Therefore, the WWD who makes it to the health unit may be traumatized and in need of understanding. The situation in our health facilities often adds insult to injury because of the hostile environment.

WWDs therefore have the following needs in accessing RH services. The need for:
1. health workers who understand the situation of WWDs and manage WWDs with empathy;
2. health units with a physical environment that is accessible to women with movement disabilities;
3. accessible information and communication for the deaf and blind
4. alternative avenues to get information about health services to WWDs.
Meeting these needs will go a long way to improving these services for WWDs.

The Role of Health Workers
RH providers do not currently meet the needs of WWDs and do not have the skills to address these needs because the basic and in-service training of health workers does not include the concerns of WWDs. As a result, RH providers often ignore, mistreat or mismanage WWDs. In a study in four districts of Uganda, WWDs reported that the biggest hindrance to accessing RH services was the negative attitude of health workers. WWDs reported that they were often ridiculed and asked why they became pregnant. For example, a woman with movement disability who was in labour on the delivery bed was humiliated when the midwife called in other health workers to come and see her. The health workers came in and the (male) doctor made a comment: ‘This is a hot one! If she wasn’t disabled, I would go for her!’ Non- disabled health workers often make cruel and derogatory comments, yet WWDs, require understanding and empathy.

Midwives, nursing aids and doctors can provide better RH services for WWDs if they receive in-service training in specific disability issues. Since disability is an unknown area to many health workers, it is essential that districts identify their training needs. The needs assessment could be carried out with disabled women as part of the enquiry team. The findings can then be used to develop a training guide(s): training in which women with different disabilities participate as facilitators can then be carried out. Where possible, this training should be mainstreamed into other RH in-service training programmes. The trained health workers should then be adequately and regularly supervised and supported by a team that includes disabled women.

Improving Physical Access and Communication
Health units are often inaccessible because they lack appropriate beds, ramps and rails to ease the movement of women with physical disabilities. WWDs reported that delivery beds are inaccessible. Bathrooms and toilets/latrines were also a major concern that discouraged WWDs from delivering in health units. Besides being inaccessible, the bathrooms and toilets were very dirty, making it difficult for women who had to crawl into these facilities to use them.

Blind and deaf women are often unable to communicate adequately with health workers and may be mismanaged as a result. Most health information is visual or audio-visual and is, therefore, not fully accessible to blind and deaf women. Few health workers know sign language.

Improving physical and communication accessibility can improve RH services for WWDs. Providing adjustable delivery beds and altering buildings by providing rails and ramps will improve physical accessibility to health facilities. Providing a stance that is adapted for WWDs (see picture below) by building a seat over the latrine hole and supporting rails will greatly improve access for WWDs. This stance should be kept clean and reserved for PWDs.

Having sign language interpreters or training two RH providers in each hospital and health centre IV in sign language will assist health workers to communicate with deaf women. Providing RH information in Braille will help blind women to access information. At present, Uganda only has one centre that prints Braille information on a large scale, based at the Uganda National Institute of Special Education (UNISE), Kyambogo. A district probably requires only 50 Braille copies of each health message. If this is not possible, an annual meeting of blind women could be arranged and health information passed to them in an appropriate way. For example, using explicit terms and allowing them to touch RH items such as pills, condoms and mama kits. The advantage of this approach is it will pass information to the many blind women who cannot read Braille. The interaction with health workers will also reduce the fear WWDs have of health unit staff.

Increasing Awareness About RH Services
Another step in improving RH services for WWDs is increasing awareness about these services in WWDs. Many WWDs do not use RH services because they do not know where these services are. This is especially so for family planning and antenatal care services. In addition to continuing current approaches of informing and encouraging all women to use RH services, WWDs require additional mobilization through disabled people’s groups, women’s organizations and local councils. A special message to WWDs is to inform them of the improvements that have been made in health units to make them disability-friendly. The best advocate for any service is a satisfied client. WWDs who come to the health units and are treated well in an accessible environment will spread the word and call on others to use the service.

Conclusion
Our health services can be modified to accommodate the special needs of WWDs. This requires changing the approach RH providers use towards WWDs, improving physical and communication accessibility and providing information about available services. WWDs know their needs best and should play a key role in adapting RH services to meet their needs. This challenge can be addressed within the available resources. We all have a role to play; a role that cannot wait for tomorrow. Will you play your part and contribute to the improvement of the lives of WWDs