ARUA, Uganda — Jennifer Anguko was slowly bleeding to death right in the maternity ward of a major public hospital. Only a lone midwife was on duty, the hospital later admitted, and no doctor examined her for 12 hours. An obstetrician who investigated the case said Ms. Anguko, the mother of three young children, had arrived in time to be saved.
Her husband, Valente Inziku, a teacher, frantically changed her blood-soaked bedclothes as her life seeped away. “I’m going to leave you,” she told him as he cradled her. He said she pleaded, “Look after our children.”
Half of the 340,000 deaths of women from pregnancy-related causes each year occur in Africa, almost all in anonymity. But Ms. Anguko was a popular elected official seeking treatment in a 400-bed hospital, and a lawsuit over her death may be the first legal test of an African government’s obligation to provide basic maternal care.
It also raises broader questions about the unintended impact of foreign aid on Africa’s struggling public health systems. As the United States and other donors have given African nations billions of dollars to fight AIDS and other infectious diseases, helping millions of people survive, most of the African governments have reduced their own share of domestic spending devoted to health, shifting to other priorities.
For every dollar of foreign aid given to the governments of developing nations for health, the governments decreased their own health spending by 43 cents to $1.14, the University of Washington’s Institute for Health Metrics and Evaluation found in a 2010 study. According to the institute’s updated estimates, Uganda put 57 cents less of its own money toward health for each foreign aid dollar it collected.
Rogers Enyaku, a finance expert in Uganda’s Health Ministry, disputed the assertion, saying the country’s own health spending had increased, “but not that substantially.” Still, the government set off a bitter domestic debate this spring when it confirmed that it had paid more than half a billion dollars for fighter jets and other military hardware — almost triple the amount of its own money dedicated to the entire public health system in the last fiscal year.
Poor people surged into Uganda’s public health system when the government abolished patient fees a decade ago. Increasingly, African countries are adopting similar policies, and experts say that many more people are getting care as a result. But Uganda’s experience illustrates the limits of that care when a system is poorly managed and lacks the resources to deliver decent services, experts say.
At regional hospitals like the one here in Arua, more than half the positions for doctors are vacant, part of a broader shortage that includes midwives and other health workers. A majority of clinics and hospitals reported regularly running out of essential medicines, while only a third of facilities delivering babies are equipped with basics like scissors, cord clamps and disinfectant, according to a 2010 Health Ministry report.
The hospital where Ms. Anguko died handles obstetric emergencies for a region of almost three million people, but it recently had no sutures in stock to sew up women after Caesarean sections. Dr. Emmanuel Odar, the hospital’s sole obstetrician, said that even in childbirth emergencies, families must buy missing supplies themselves, typically at nearby pharmacies. Patients without money must beg or borrow it, Dr. Odar said.
“We are overwhelmed with cases of people looking for free services, and they expect a lot despite supplies not there, human resources lacking and the beds not enough,” he said.
Dr. Olive Sentumbwe-Mugisa, a Ugandan obstetrician and adviser with the World Health Organization, participated in the Health Ministry’s investigations of the deaths of both Ms. Anguko and Sylvia Nalubowa, a second woman named in the lawsuit against the government, and concluded that both women arrived in time to be saved.
“We are in a state of emergency as far as maternal services are concerned,” Dr. Sentumbwe-Mugisa said. “We need to focus on the quality of care in our hospitals and address it in the shortest period of time. That will mean more resources. We cannot run away from that.”
In its lawsuit filed in March, the Center for Health, Human Rights and Development, a Ugandan nonprofit group, contended that the government violated the two women’s right to life by failing to provide them with basic maternal care.
The attorney general’s office replied that the “isolated acts” cited in the case “cannot be used to dim the untiring efforts in the Health Sector.” It also noted competing priorities for “the meager resources at the state’s disposal.”
But the government has come in for tough questioning since April, when its spending on the Russian-made fighter jets became public, helping fuel protests.
Officials in President Yoweri Museveni’s government say the jets are critical to protecting Uganda in a region with a history of conflict, especially as the country develops its oil fields. “The enemies of Uganda don’t want us to have those jet fighters,” said Tamale Mirundi, a spokesman for Mr. Museveni.
But opposition leaders denounced the spending in a nation at peace, with huge social needs.
“You are talking about investing in jets? Come on!” exclaimed Christine Bako, a lawmaker from Ms. Anguko’s district, during a debate in Parliament. “This is now a matter of conscience.”
As her due date approached, Ms. Anguko left her village to live with relatives near the big hospital in Arua, 300 miles northwest of the capital, Kampala. In preparation, she and her husband bought the supplies they knew the hospital lacked: latex gloves, cotton wool, a razor blade to cut the umbilical cord.
On a Sunday morning last year, after praying in church, Ms. Anguko felt abdominal pains and went to the hospital. That afternoon, her husband, standing just outside the ward, heard her urgently calling. She told him that she was bleeding and that no one was attending to her, he said. He and his wife’s cousin, Jane Adiru, 33, said they repeatedly approached the nurses for help over the following hours, but were ignored.
The hospital’s own account depicted a nightmarish day of complicated emergencies with only one midwife for both the day and evening shifts. Women arrived with ruptured uteruses, a stillbirth, an obstructed labor, an incomplete abortion and a bleeding cancer of the cervix.
No doctor examined Ms. Anguko until about 12 hours after she was admitted, according to the hospital’s own account. Another hour passed before she finally got into surgery. By then it was too late. She and the baby died.
“Arua Hospital is not happy with what happened and regrets the whole thing,” the hospital’s superintendent wrote to angry leaders of the district council on which Ms. Anguko had served.
As Africa’s population swells, so will demand for emergency obstetric care. The United Nations recently estimated that Uganda’s population will almost triple to 94 million by 2050, with tens of millions more babies to be delivered.
As it is, about 80 percent of the world’s maternal deaths occur in just 21 nations, 15 of which are in sub-Saharan Africa, according to the University of Washington study. Uganda was among them. About 5,200 women died from pregnancy-related causes in the country in 2008, the researchers estimated.
Dr. Rafael Lozano, a professor at the university, said that except for recent gains in saving the lives of H.I.V.-positive pregnant women with antiretroviral treatments largely financed by donors, “you see basically almost no progress in maternal deaths in Uganda.”
When Ms. Nalubowa, 40, a peasant farmer and a mother of seven, arrived at the decrepit hospital in Mityana, said her mother-in-law, Rhoda Kukkiriza, nurses demanded a bribe of about $24 and more money to buy airtime for a cellphone call to the doctor, accusations the nurses have denied. Ms. Kukkiriza said she had less than a dollar left after spending $2.40 to buy a razor blade, gloves and other items the hospital lacked. Unable to pay the bribe, Ms. Nalubowa was taken to the maternity ward and left unattended, her mother-in-law said.
“As she pushed with the labor pains, all that came out was blood,” Ms. Kukkiriza said. “Sylvia called out, ‘I’ll sell all my pigs, I’ll sell my chickens, my goats — please, nurses, come help me.’ ”
Even if a doctor had arrived promptly, the hospital staff would have struggled to save Ms. Nalubowa, who bled to death. Dr. Vincent Kawooya, the hospital’s medical superintendent, said there was only one small unit of blood for a child in stock that night.
The health minister himself toured the hospital after Ms. Nalubowa’s death incited demonstrations, but Dr. Kawooya said the minister refused to set foot in the operating room, with its moldy walls and leaky ceiling, saying it should be condemned. The roof of the maternity ward was a home to bats, and droppings come down its inner walls.
Vincent Nyanzi, a governing party lawmaker from the area, said he introduced Ms. Nalubowa’s mother-in-law and husband to President Museveni when he visited a nearby district.
The president’s secretary gave them an envelope containing about $190, the family said. In their brief audience with the president, Ms. Kukkiriza said, he told them: “ ‘I’m sorry. It’s really a pity.’ ”