According to the most recent global data on maternal mortality, 536,700 women died of maternal causes in 2005. Sub-Saharan Africa accounted for more than half of the world’s maternal deaths each year (WHO 2007). And, at 900 deaths per 100,000 live births, Sub-Saharan Africa has almost double the rate of maternal deaths of the next-highest region, South Asia, and a rate 100 times higher than that of developed nations (WHO 2007). The disparities in maternal deaths are staggering. A 15-year-old female in Sub-Saharan Africa has a 1 in 26 chance of death related to maternal causes in her lifetime compared with a 1 in 7,300 chance if she lived in the developed world (WHO 2007).
Maternal mortality in Sudan
The causes and rate of maternal death in Sudan, while similar to that of other nations in Sub-Saharan Africa, are exacerbated by ongoing conflict and subsequent displacement. Indeed, key indicators related to maternal health – maternal mortality, child (under the age of five) mortality and child malnutrition – are all exacerbated by conflict (O’Hare and Southall 2007). The maternal mortality rates for Sudan – which has 10 times more landmass than the UK -vary greatly, from 590 maternal deaths per 100,000 live births in Northern Sudan to 1,700 maternal deaths per 100,000 live births in Southern Sudan (New Sudan Center for Statistics and Evaluation 2004). While the exact maternal mortality rates for the three western Sudan states experiencing the brunt of conflict in the country (West, North and South Darfur) are unknown, they are estimated to approach the higher estimate. In short, the three states in the Darfur region are likely to be among the five deadliest places in the world in which to give birth.
The work of International Medical Corps
International Medical Corps works in 14 static and seven mobile clinics throughout West and South Darfur, providing health care to 450,000 people. In all of its clinics, International Medical Corps works with other organizations collectively to ensure the provision of the World Health Organization’s Minimum Initial Service Package (MISP) for reproductive health in crisis situations. The MISP is a set of priority reproductive health services to be initiated by humanitarian actors at the onset of a crisis situation, and is standard practice in humanitarian aid. Key elements of the MISP include coordination of reproductive health activities; prevention of sexual violence and assistance to survivors; reduction of HIV transmission; prevention of excess maternal and neonatal death; and planning for the mainstreaming of reproductive health into primary health care following the crises. With support from the United States Office for Foreign Disaster Assistance, the Netherlands Refugee Foundation Stichting Vluchteling and other private donors, International Medical Corps provides the MISP – including cesarean sections and blood transfusions – at the Um Dukhun health facility, a border town in the West Darfur state of Sudan.
Barriers to care
Um Dukhun health facility is staffed with 28 clinical personnel and 31 community-based health workers who are actively involved in community sensitization, health education and health promotion activities. Open 24 hours a day and seven days a week, it serves a catchment population of 125,000 people. The majority are internally displaced persons or refugees from neighboring Chad or the Central African Republic.
International Medical Corps has served this population since 2006, and has observed the obstacles women must overcome in order to receive consistent and timely antenatal and postnatal services. During the two planting and harvesting seasons there is a marked decrease in attendance at clinics as women are busy tending to their crops. Some husbands do not want their wives to go to the clinic for fear they would be examined by a male clinician. In addition, there are rumors that clinics secretly try to sterilize women or force them to use contraception. Some women who do come to the clinics refuse medication and supplements because they fear they may be harmful. Other women are understandably afraid to travel to a clinic, which may be several kilometers away, fearing they will be sexually assaulted during their journey.
While it can often be difficult to provide women with the requisite antenatal or postnatal care in Um Dukhun due to familial, personal or other concerns, it is even more difficult to provide timely emergency obstetric and neonatal care in a chronically insecure community that lacks adequate roads, electricity and communications. Statistics show that in an emergency setting 15 per cent of pregnancies require emergency obstetric care, and 5 to 15 per cent of all pregnancies require a cesarean section (Maine et al 1997).
Unfortunately, the need for emergency obstetric care in Um Dukhun is even more acute: UNICEF estimates – and International Medical Corps’ experience supports this – that 65 per cent of women in Darfur have undergone type 3 (infibulation) female genital mutilation (FGM). Research shows that women who have undergone type 3 FGM are significantly more likely to require a cesarean section (31 per cent increased risk), experience postpartum hemorrhage (69 per cent increased risk) and have poorer birth outcomes (55 per cent increased risk of stillbirth or early neonatal death) (WHO Study Group on Female Genital Mutilation and Obstetric Outcome 2006).
Despite these known needs for emergency obstetric care, women in Darfur still delay seeking and receiving appropriate care. Many believe it is shameful to give birth outside the home, and would prefer to risk a difficult labor attended only by older female relatives or a local traditional birth attendant (TBA). Many TBAs have never received any formal training, are unable to identify a complicated labor, and sometimes delay referral to the health facility until it is too late. Yet other TBAs do not refer cases – even when they feel the woman requires emergency obstetric care -through fear of losing payment for delivering the child at home. Even when women decide to seek care, travel to the International Medical Corps health facility in Um Dukhun is difficult. Almost half of women in the catchment area live more than 5km from the health facility; have no personal transport; and the cost of motorized or animal transport, if available, is prohibitive.
International Medical Corps addresses the aforementioned barriers to seeking antenatal and postnatal care and emergency care; and increases safe, home-based, uncomplicated birth through community-based training, education and the provision of comprehensive emergency obstetric care at the Um Dukhun health facility. On the community level, International Medical Corps appreciates the important role TBAs can play in providing education and in recognizing and referring life-threatening complications for emergency care. International Medical Corps has undertaken training regimens with TBAs that focus on:
- providing community and individual health education to increase antenatal care-seeking behaviors and dispel myths of clinical care, drugs and supplements
- the utilization of clean delivery kits provided by International Medical Corps
- recognizing ante and postpartum hemorrhage, prolonged or obstructed labor, postpartum sepsis, ectopic pregnancies and ruptured uterus in order to facilitate timely referral to the health facility
- provision of home-based postnatal care following uncomplicated births.
International Medical Corps works closely with religious leaders to increase awareness among the mostly male constituents of the utility of antenatal care and the importance of timely emergency obstetric care-seeking behavior. Local authorities have also been engaged to increase police posts in rural areas to address travel concerns related to sexual assault. In addition, a system is being established to support travel to the health facility with the provision of a horse/donkey cart and the reimbursement of expenses related to travel costs. Finally, International Medical Corps is establishing an incentive system to encourage TBAs to refer obstructed or prolonged labor and pregnant women to seek timely antenatal and postnatal care. TBAs are most effective in reducing maternal mortality when they are supported by a health facility – such as the one sponsored by International Medical Corps in Um Dukhun – that provides comprehensive emergency obstetric care (Weil and Fernandez 1999).
International Medical Corps’ efforts have been successful in the past 12 months. In the year ending September 2008, International Medical Corps trained 149 TBAs; 2,493 women (49.3 per cent of an expected 5,058 pregnant women) received at least two antenatal visits; 3,018 women (59.7 per cent) were given clean delivery kits; 307 women(6.1 percent) were provided with emergency obstetric care; 231 women (4.6 per cent) received cesarean sections; 1,506 women (29.8 percent) received postnatal care; and the health facility recorded three maternal deaths, all related to fulminant hepatitis.
These data are promising, but there is much work still to be done. Antenatal coverage and the provision of emergency obstetric care must increase. Surveillance systems must be put in place better to monitor births and deaths. General reproductive health must be further promoted, gender-based violence must be curbed, and the continuum of care for mother and baby after birth must be further strengthened to promote child survival.