Sudan: Situational analysis of maternal health in Bara District, North Kordofan
Abstract: A high maternal mortality ratio was estimated in Bara District in Sudan during the late 1980's with approximately 407 women dying per 100000 live births. In order to design effective intervention strategies, Care International and the Ministry of Health in Sudan conducted a study to identify the attitudes of women, staff, and TBAs towards motherhood, prenatal care, and practices affecting the health of women in the district. The previously conducted training programme for TBAs was also assessed in its impact. The study yielded the following results: in addition to the commonly known risk factors for maternal health e.g. haemorrhage, puerperal infection, obstructed labour, and anemia, the women in the villages and health staff identified female genital mutilation (pharaonic circumcision) as a major threat to safe motherhood. Health seeking behaviour was linked to problems of access and perceived quality of care: women did generally not wish to spend more than 30 minutes for reaching a facility. But if the quality of a particular institution was considered good, and supplies and equipment were available, women would cover great distances to reach such a facility. Participation in prenatal care suffered from the equation of preventive with curative care. Women would therefore tend to turn to a clinic or service provider, if symptoms of illness occurred during a pregnancy. The village-based services suffered from the lack of equipment and poor staff training, which further undermined the motivation to seek prenatal care. When health staff recommended referral of a pregnant woman for delivery, the advice was usually followed. But the decision to refer had to be agreed upon by the husband which caused delays when a husband was absent and could not be reached quickly. Lack of transport posed a problem for timely referral. Delayed recognition of risk conditions by some health staff and untrained TBAs was also identified. Further delays upon arrival at a facility were considered problematic. Postnatal care was seen as insufficient and in particular with a view to controlling infections which are common amongst circumcised women after delivery. The ideal birth interval was considered to be 2 to 4 years, but it effectively was 18 to 24 months. For reasons of birth spacing women were interested in learning more about modern contraceptives. The completed TBA training programme was generally regarded as satisfactory by the women and health staff in the communities particularly in view of the improved skills of TBAs to provide for timely referral. But there was need to establish supervisory mechanisms and support to the TBAs after conclusion of the training programme. This would enhance the TBAs newly acquired knowledge and re-inforce use of the materials in their TBA kit. The TBAs regarded the course programme as having been too lengthy and having surpassed their capacity to absorb all the information offered. The child care component of the course did not seem to have met its target as it did not correspond to the traditional role perception of TBAs as providers of delivery care only.
Care International and the Ministry of Health in Sudan used interviews, focus group discussions, and observations in their exploration of the attitudes of women, staff, and traditional birth attendants (TBA) toward motherhood, prenatal care, and practices affecting the women's health in the rural councils of Bara, Gerejikh, and Taiyba, Bara District. It was in this district during the late 1980s that approximately 407 women died per 100,000 live births. The study was designed and implemented over the period March-July 1990. Village women and health staff noted hemorrhage, puerperal infection, obstructed labor, anemia, and female genital mutilation as major threats to maternal health. Women did not want to spend more than thirty minutes reaching a health facility. If, however, the quality of a particular institution were considered good, and supplies and equipment were available, women would go far to reach that facility. It was found that women are unmotivated to seek prenatal care services because they do not understand that prenatal care exists to prevent morbidity and mortality, and village services also lack the necessary equipment and properly trained staff. The need to secure a husband's approval, lack of transport, and the delayed recognition of risk conditions by health staff and TBAs all delay the provision of treatment for women referred for delivery. Finally, postnatal care was inadequate, the women want to learn about birth spacing methods, and a completed TBA training program was generally regarded as satisfactory by the women and health staff in the communities.