Every year, a tetanus outbreak ravages Iganga district, killing over 150 infants. And the situation is bound to get worse, given the local birthing practices.

Iganga, the third-largest district in Uganda, now faces an uphill struggle against deep-seated cultural beliefs if it is to reverse the needless infant deaths, says Lydia Kibwika Kasinda, vice-chair of the local council. People here believe in delivering in banana plantations. "They say you should hold a banana plant during labor," says Kasinda. "The labor is believed to be short and quick then." The newborn is later laid on a banana leaf.

Women also use contaminated instruments as rusted razor blades, knives and reeds to cut the umbilical cord, raising the chances of tetanus infection. The biggest threat, however, is what the women use to heal the navel - cow or sheep dung, lizard droppings and soot.

District Health Educator Sister Eva Suubi blames this for the rise in tetanus. "People believe these will heal the navel and make the cord drop off early from the baby, thus allowing women to resume their normal duties of working in the fields and sleeping on a bed." Local traditions decree that a woman who has just delivered and her baby are unclean and, therefore, unfit to sleep on a bed. According to Suubi, the unhygienic conditions of birth and subsequent practices are the primary cause of many infant deaths.

Suubi says neonatal tetanus can be prevented and eliminated. Tetanus or 'lock-jaw' is caused by a germ that grows in dead tissue and decaying matter. The possibility of infection is most common with manure, dust, dung, or rusty tools such as nails, reeds, needles, old razor blades, barbed wires and wood splinters. Tetanus attacks infants aged three to 28 days. Symptoms include crying and spasms. The baby stops suckling and has difficulty in breathing.

And, when the infants die, it is up to the women to bury them. Local men only recognize the baby only when it grows its first teeth; until then it is not a 'real' baby. "Men believe that as long as the women are unaffected, there is no cause for worry," she adds.

With the help of UNICEF, the district has embarked on a massive immunization programme. But the people are reluctant to come forward, says District Director of Health Services D G Muwanguzi. "The services are there; we have clinical centers where women can seek medical help but people are not willing to come," Muwanguzi says. "They associate immunization with infertility."

Besides, many women report that they need the permission of their husbands to seek these services. Social worker Margaret Masege says they are working on a sensitization campaign to bring the men on board and educate them on the importance of allowing their wives to go for antenatal and post-natal checks. She says: "We have realized that once the men are knowledgeable about the causes of infant deaths, they do let their wives visit clinics. Sometimes they accompany them."

Muwanguzi says 54 tetanus deaths were reported in Iganga between January and June, but the figure could be higher because many deaths go unreported. Says Suubi, "Those are the reports we receive at health centers, and they account for about 15 per cent. You have to triple that to get the real picture on the ground."
District leaders worry that the situation might get out of control. UNICEF has quickly responded with money for vaccines. "Tetanus means death in most cases. Iganga is the most affected, but 31 other districts are also at risk," says Lukyamuzi Mbidde, the regional manager.

Local people associate tetanus with witchcraft and evil spirits in the family, so they try to keep the disease as secret as possible instead of seeking immediate treatment.

According to Masege, men's reluctance to help pregnant women or their babies adds to the problem. "Men don't care whether the women get adequate health care before or after delivery. We are encouraging them to get involved, since men make the major decisions affecting their wives. Men are also the ones with the money to send women to hospitals. They are the gatekeepers of tradition. We want them to encourage their women attend antenatal clinics and to go for routine immunization. Therefore, health authorities are planning to involve men at all levels of a massive immunization campaign."

Studies suggest that educating prospective fathers in reproductive (especially antenatal) health has a positive impact on their women and children. Such men are more concerned about their partners' health needs during and after pregnancy.