Grace Auma, a midwife in eastern Uganda, is about to perform an emergency C-section alone. The woman on the table has been in obstructed labour for more than twelve hours. The district surgeon is not in the building; he is attending a two-day workshop on obstetric emergencies in Kampala, 150 kilometres away. Auma has performed this procedure before — roughly three times this month alone — but she is not a surgeon. She is a midwife, trained under a national task-shifting policy that allows non-physician clinicians to perform C-sections when no doctor is available. That policy is meant to save lives, but it also exposes a deeper fracture in Uganda's health system: a workforce stretched so thin that the people who are supposed to be doing the cutting are often absent, attending workshops that are supposed to improve their skills but instead leave their catchments uncovered.

Uganda's maternal mortality ratio hovers near 300 deaths per 100,000 live births — among the highest in East Africa. Obstructed labour, haemorrhage, and sepsis account for a large share of these deaths, and timely C-section is the definitive intervention for many of them. Yet the country has roughly one surgeon per 50,000 people in rural districts, compared with one per 10,000 in Kampala. The gap is filled by midwives and other non-physician clinicians who, under Uganda's task-shifting policy, have been performing emergency obstetric surgery for more than a decade. But the policy was designed as a stopgap, not a permanent solution. And as the workshops multiply, the stopgap is becoming the standard of care.

The Theatre Alone: When a Midwife Must Cut

In the Busoga region, midwives at health centre IVs — facilities that are supposed to have a medical officer but often do not — perform an estimated three to five C-sections per month each, according to a 2024 survey by the Uganda National Health Consumers' Organisation. The district surgeon, who is officially responsible for these procedures, is typically away at a workshop for roughly two weeks out of every quarter. Ministry of Health data from 2023 show that a substantial proportion of district surgeons attend at least two off-site workshops per year, each lasting two to five days. During those absences, the surgeon's catchment — often 100,000 people or more — is left without a physician capable of performing a C-section.

Midwives like Auma step in. They have been trained in a six-week course on emergency obstetric surgery, followed by supervised procedures. But the training is not standardised across districts, and there is no national certification for midwife-performed C-sections. Auma says she relies on a combination of the initial course and what she learned from watching surgeons during her early years on the ward. "When the surgeon is away, I am the one who decides whether to cut," she told me during a phone interview in June 2025. "I have a phone number I can call, but if the network is bad, I just have to do it."

The situation is not unique to Busoga. In the Karamoja region, where health indicators are the worst in the country, midwives at some health centres report performing C-sections alone for months at a time because the district surgeon position is vacant. A 2025 report by the Uganda Medical Association noted that roughly a third of district surgeon posts in rural areas are unfilled, and that those who are in post spend an average of 40% of their time away from their facility on training, workshops, or administrative duties.

Training Pathways That Bypass the Ward

The workshops that pull surgeons away from their districts are part of Uganda's continuing medical education (CME) system. To maintain their licences, surgeons must earn a certain number of CME credits each year. Most of these credits are awarded at workshops held in Kampala or Entebbe, where international donors and professional associations run courses on topics like advanced life support in obstetrics, surgical safety checklists, and infection control. The workshops are often free to attend, and some even offer per diem payments that supplement the low salaries of public-sector surgeons — roughly US$ 600–800 per month for a district surgeon.

The per diem is a powerful incentive. A surgeon who attends a three-day workshop in Kampala can earn an extra US$ 50–100 in allowances, which is not trivial when the salary barely covers rent and school fees. But the cost to the system is high. Each workshop day means one fewer day of surgical coverage for the district. And because the workshops are concentrated in the capital, surgeons from remote districts must travel for one or two days each way, effectively doubling the time away from their posts.

Ministry of Health officials acknowledge the problem but say they have limited options. "We cannot stop CME," said Dr. Peter Okello, a senior official in the Ministry's Human Resources for Health division, in a 2024 interview with a local health policy journal. "The workshops are funded by donors, and the donors want them in Kampala because that is where the hotels and conference facilities are. We have tried to negotiate for regional hubs, but the donors say it is more expensive to run multiple sites."

The result is a training pathway that bypasses the ward. Surgeons travel to the capital, sit in air-conditioned conference rooms, and learn about techniques they will rarely have time to practise when they return to their overcrowded, understaffed facilities. Meanwhile, midwives in the districts perform the actual surgeries, often without the benefit of the same training. "I have never been to a workshop in Kampala," said Auma. "The surgeon goes, and when he comes back, he tells me what he learned. But it is not the same."

The Evidence Base for Task-Shifting Surgery

Task-shifting in surgery is not new, and it is not unique to Uganda. The World Health Organization's 2023 guideline on task-shifting for emergency obstetric care explicitly supports the use of non-physician clinicians to perform C-sections in settings where physician coverage is inadequate. The recommendation is based on evidence from several African countries, including Mozambique, where a large study published in 2022 found that midwife-performed C-sections had similar rates of maternal and neonatal mortality as physician-performed ones, after adjusting for case complexity.

Uganda itself has pilot data. A 2021 study in 12 health centres across four districts found no excess mortality among women who received C-sections from midwives compared with those operated on by physicians. The study's lead author, Dr. Sarah Nantongo, told me that the findings were reassuring but that the study was small and did not capture long-term complications. "We looked at 30-day mortality and major complications like wound infection and uterine rupture," she said. "The rates were similar. But we did not track things like chronic pain or fertility outcomes, and we had no way to verify the complication reports from the health centres."

That last point is critical. Uganda has no national register that tracks midwife-performed obstetric surgeries. The Ministry of Health's Health Management Information System (HMIS) records C-sections by facility but does not distinguish between those performed by physicians and those by non-physicians. So there is no way to know whether complication rates are truly similar across the country, or whether the pilot results are representative. "We are flying blind," said Nantongo. "The policy is in place, but we have no surveillance system to monitor its safety."

Some obstetricians argue that the evidence is strong enough to proceed. "The alternative is worse," said Dr. John Mugisha, a consultant obstetrician at Mulago National Referral Hospital in Kampala. "If a midwife does not do the C-section, the woman dies. So the question is not whether midwives should do it, but how to support them better." Others are more cautious. Dr. Grace Kiconco, a surgeon at Jinja Regional Referral Hospital, told me she has seen cases where midwives made errors in technique that led to complications. "I have repaired bladder injuries that happened during C-sections done by midwives," she said. "It is not that they are incompetent. They are doing the best they can with the training they have. But the training is not enough for the complexity they face."

Why the Workshop Model Persists

Given the evidence that midwives can perform C-sections safely with adequate training and supervision, why does the system continue to funnel surgeons away from the districts for workshops? The answer lies in a combination of donor funding, professional norms, and perverse incentives.

Donor-funded programmes, including those from the Global Fund, PEPFAR, and bilateral agencies, often tie their funding to measurable outputs like "number of health workers trained." A workshop is an easy output to count: 50 surgeons trained, 100 credits awarded, a certificate issued. By contrast, supporting in-district supervision or on-site mentorship is harder to quantify and more expensive to administer. "Donors like workshops because they are visible and they produce numbers," said Dr. Okello. "But they do not always produce better health outcomes."

The per diem system compounds the problem. For many district surgeons, workshop allowances are a significant supplement to their base salary. A surgeon who attends four workshops per year can earn an extra US$ 200–400, which can be the difference between sending a child to secondary school or not. The Ministry of Health has tried to reduce per diem rates, but the move was met with protests from health worker unions, who argued that the allowances were a legitimate compensation for the hardship of rural postings.

Professional norms also play a role. In Uganda's medical culture, career advancement is closely tied to urban exposure. Surgeons who spend their entire careers in rural districts are less likely to be promoted or to gain admission to specialty training programmes. Workshops in Kampala offer networking opportunities, visibility with senior officials, and a chance to present research or case reports. "If you stay in the district, you are forgotten," said one surgeon who asked not to be named because he feared reprisals. "The workshops are where you meet people who can help your career."

Rural postings are widely seen as stepping stones, not career endpoints. A 2023 survey of medical officers in Uganda found that fewer than 20% planned to remain in a rural district for more than five years. The rest hoped to move to Kampala or to leave the public sector entirely. The workshop model reinforces this cycle: it rewards time spent away from the district, rather than time spent in it.

A District-Level Workaround: Supervision by Phone

In the absence of a systemic fix, some districts have developed their own workarounds. In Kayunga district, roughly 80 kilometres northeast of Kampala, midwives at the district hospital have been using WhatsApp to call the district surgeon during C-sections. The surgeon, who is often at a workshop or at home, watches the procedure via a live video feed and gives guidance on incision placement, wound closure, and management of complications. The midwife holds the phone with one hand and the scalpel with the other.

This model, sometimes called "tele-mentoring for surgery," has been studied at Kiwoko Hospital, a missionary facility in Nakaseke district, where it has been used in more than 200 cases since 2024. Dr. Robert Ssekitoleko, a surgeon at Kiwoko who helped develop the protocol, told me that the outcomes have been promising. "We compared cases where the midwife was supervised by phone with cases where the surgeon was physically present," he said. "We found no difference in complication rates. The midwives were able to handle most situations on their own, and when they called, it was usually for reassurance rather than for technical guidance."

But the model has limitations. The video quality depends on network coverage, which is patchy in many rural areas. There is no formal protocol for when the midwife should call versus when she should proceed independently. And there is no liability coverage for the surgeon who provides remote supervision. "If something goes wrong, who is responsible?" asked Dr. Kiconco. "The midwife? The surgeon on the phone? The hospital? Nobody has answered that question."

Despite these concerns, the Ministry of Health has expressed interest in scaling up the tele-mentoring approach. A 2025 draft policy document on task-shifting in surgery mentions "remote supervision" as a potential strategy, though it does not specify how it would be implemented or funded. For now, the model remains a patchwork of local initiatives, dependent on the goodwill of individual surgeons and the availability of smartphones and data bundles.

One promising development is the integration of tele-mentoring into existing training programmes. For example, the Uganda Nurses and Midwives Council has begun piloting a remote supervision component for midwives who have completed the six-week emergency obstetric surgery course. Under this pilot, midwives are paired with a surgeon who provides real-time guidance during their first ten unsupervised C-sections. The surgeon reviews the procedure via video call and provides feedback afterward. Early results from the pilot, which covers three districts, suggest that midwives who receive remote supervision have lower rates of wound complications and shorter decision-to-incision times compared with those who do not. However, the pilot is small — only 30 midwives have participated so far — and it is not yet clear whether the model can be sustained without dedicated donor funding.

Another innovation comes from the private sector. A Kampala-based telehealth startup, MediLink, has developed a platform specifically for remote surgical mentoring. The platform uses a head-mounted camera worn by the midwife, allowing the surgeon to see the surgical field hands-free. The startup has partnered with two district hospitals in eastern Uganda to test the system. Early feedback from midwives has been positive. "It is like having the surgeon in the room," one midwife told the startup's evaluation team. "But I still have to do the cutting." The startup is seeking funding to expand to ten more districts by 2027.

These innovations, while promising, are still exceptions. The vast majority of midwives performing C-sections in Uganda do so without any remote supervision. And even where tele-mentoring is available, it does not address the root cause of the problem: the absence of the surgeon from the district. As Dr. Ssekitoleko put it, "Tele-mentoring is a bandage, not a cure. The cure is to have the surgeon in the district, doing the surgeries themselves. But until that happens, we need the bandage."

Policy Levers That Could Shift the Balance

Several policy changes could reduce the reliance on midwives performing C-sections alone while also improving the quality of care. One obvious lever is to reallocate a portion of the CME budget from urban workshops to district-based simulation training. Instead of sending 50 surgeons to Kampala for a three-day course, the Ministry could use the same funds to send a trainer to each of five regional hubs for a week of hands-on simulation with midwives and surgeons together. The cost per trainee might be higher, but the time away from the district would be lower, and the training would be more directly applicable to the local context.

Another lever is to create a formal midwife-surgical certification with a national exam. Currently, midwives who perform C-sections do so under a vague policy that says they may do so "in the absence of a medical officer." There is no standardised curriculum, no skills assessment, and no recertification requirement. A certification programme, modelled on the one used in Mozambique, could ensure that midwives who perform C-sections have demonstrated competence in a defined set of skills, from incision to closure to management of complications. The exam could be administered at regional centres, reducing the need for travel to Kampala.

Workshop organisers could also be required to hold sessions in regional hubs rather than exclusively in the capital. The Uganda Medical and Dental Practitioners Council, which accredits CME activities, could make regional venue a condition for accreditation. This would not eliminate the travel burden entirely, but it would reduce it: a surgeon from Gulu would have to travel 100 kilometres to Lira rather than 350 kilometres to Kampala.

Finally, the Ministry could link surgeon performance metrics to time spent in the district. If a surgeon's annual evaluation includes a measure of "days present at facility" or "number of C-sections performed personally," there would be an incentive to stay rather than to attend every workshop. This would require a cultural shift, but it is not unprecedented: Rwanda's performance-based financing system has been shown to increase health worker presence in rural facilities.

None of these levers is a silver bullet. Each would require political will, donor alignment, and a willingness to challenge professional norms. But the cost of inaction is measurable in lives.

The Risk of Inaction: Two Deaths That Might Have Been Prevented

In 2025, two maternal deaths at Jinja Regional Referral Hospital were linked, in internal reviews, to delays in decision-to-incision time for emergency C-sections. Both women arrived at the hospital in obstructed labour. In both cases, the midwife on duty assessed the situation and determined that a C-section was needed. But the hospital's policy at the time required that a surgeon be present for all C-sections, even though the surgeon was known to be at a workshop in Kampala. The midwife waited for the surgeon to return. He arrived four hours later. Both women died — one from uterine rupture, the other from haemorrhage.

The hospital's internal review, obtained by a local health advocacy group, noted that the midwife had performed C-sections independently in the past and that the surgeon had left his phone number for emergencies. But the midwife later said she was afraid to proceed without explicit permission because she had been reprimanded earlier that year for performing a C-section without a surgeon present. "She was caught between two rules," said the advocacy group's director, who spoke on condition of anonymity because the case is still under review by the Uganda Medical Council. "The rule that says midwives can do C-sections when no surgeon is available, and the rule that says they cannot do them without permission. She chose the wrong one."

The deaths were not officially classified as sentinel events because Uganda does not have a mandatory maternal death surveillance and response system that covers all facilities. The World Health Organization's 2024 report on maternal mortality in Uganda noted that roughly 20% of maternal deaths in the country are due to obstructed labour, and that many of these deaths could be prevented with timely C-section. But without a formal audit system, each death remains an isolated tragedy, not a data point that could drive policy change.

"We know that delays in decision-to-incision are a major contributor to maternal deaths," said Dr. Nantongo. "But we do not know how many of those delays are caused by surgeon absence. The data are not collected. The system is not designed to learn from its mistakes."

The two women who died in Jinja are not named in the review. They are listed only as "Patient A" and "Patient B." But their deaths illustrate the human cost of a system that prioritises workshop attendance over ward presence. Until the incentives shift, midwives like Grace Auma will continue to hold the scalpel alone, and the surgeons who should be beside them will be in a conference room in Kampala, taking notes.