Sudan: Maternity care in rural North Darfur
Fifteen-year old Sameera* had already been in labour for two days when her family decided to leave the valleys and farming plots of Jurajeem to seek the help of a doctor. After a day’s journey they arrived in Um Baru, a town in the Dar Zaghawa region of Sudan, where Médecins Sans Frontières (MSF) runs a health centre. Midwife Halom Abdallah found the baby’s head pressing on the mother’s bladder. Not only did this put Sameera at risk of developing a fistula, but the World Health Organization (WHO) says that most maternal deaths occur during, or right after delivery; it is the most dangerous time for both mother and child. Fortunately, three hours after she arrived at the MSF health centre Sameera delivered a healthy baby boy.
In Dar Zaghawa region, countless pregnant women like Sameera seek medical care once their situation is critical, and often it is too late. Sameera and her baby are two of the lucky ones. The latest Sudan Health Household Survey (from 2010) says that 640 women in North Darfur die during childbirth for every 100,000 babies born there, compared to 389 per 100,000 live births in Khartoum. According to the WHO (from 2010), an average of 20 women in Europe die during childbirth for every 100,000 babies born there.
Babies lives are also at risk in Sudan: The neonatal mortality rate is at 33 per 1,000 live births, compared to an average of about seven per 1,000 live births in many European countries (WHO 2010).
“Women in the area often deliver at home with assistance from traditional birth attendants who do not have the essential training or skills to tend to women with complicated deliveries.” says Halom. “In cases like Sameera´s, where she is a first-time mother, there’s a great chance we may lose the child, mother or worse, both.”
At the highest risk for complications are adolescent pregnancies, as the mother’s body has not fully developed. The pelvis has not reached its full size and this may result in obstructed labour, putting at risk both the mother and baby. Because young mothers’ bodies are still developing, the additional needs of the growing fetus put them at higher risk of anemia and post-partum hemorrhage. The babies may be born prematurely and have a lower birth weight. The support of a midwife, medical doctor or obstetrician during labour, delivery and in at least the first hours after birth is essential for both the young mother and the newborn.
The reality is that there are not enough health facilities or birth attendants to serve the women of Dar Zaghawa region, despite a population of more than 20,000. Other than the two MSF doctors and one MSF midwife, the three Ministry of Health midwives are the only skilled birth attendants able and equipped to manage complications related to labour and delivery. In Um Baru, about 300 kilometres from Elfasher, the capital of North Darfur state, Halom is the only midwife in the area. Yet for many women, Um Baru is the closest health facility. It took Sameera an entire day to get here by donkey cart. By car, the journey would have been just a couple of hours long, but few can afford to rent a car even when a baby is on its way.
“In 2012, we delivered over 900 babies in North Darfur. However, educating women on the importance of a safe delivery in the hospital is another crucial part of the equation,” says Fernando Medina, MSF Head of Mission in Sudan. “Last year we had over 50 community health workers in MSF-supported health facilities in Dar Zaghawa, Shangil Tobaya and Tawila, visiting people to discuss the benefits of seeking antenatal and postnatal care, a safe delivery in the hospital, family planning, breastfeeding, and vaccinations. We have seen a five-fold increase in the number of women seeking postnatal care and we have seen over 12,500 women during pregnancy. But we still want to reach more women.”
When women come to the health centres during pregnancy, health practitioners are able to follow the health situation of the mother and baby, discuss birth options and prepare mothers for delivery. Antenatal care is critical for determining risks and detecting complications that can impact the mother and baby’s health early on.
Even after a healthy delivery, the next few hours are critical. When no skilled care is provided, the WHO reports that one fourth of all newborns die in the first 24 hours. Pro-longed or obstructed labour leading to fetal distress, newborns with pre-mature and low-birth weight, birth trauma and respiratory distress can all lead to neonatal death.
Post-partum hemorrhage and infection are the main causes of maternal death. Yet, even in resource-poor settings like Um Baru, it is relatively easy to prevent these deaths. But saving the lives of mothers and babies involves medication and specific skills. Post-delivery consultations allow health workers to monitor mothers’ and babies’ well-being for six weeks after birth, help with breastfeeding, identify and treat infections, take care of routine vaccinations for the baby and offer family planning. If a case is too complicated, women are referred to Elfasher Hospital and MSF covers all transportation and medical costs for the women and their caretakers.
In addition to health centres, other facilities gaining acceptance and popularity in these settings are maternity waiting houses, where women from remote areas with at-risk pregnancies can stay near the medical facility a few weeks before their due date to ensure they can get to hospital when labour begins. MSF, which runs several of these facilities around the world, this year opened a 20-bed maternity waiting house in Tawila locality, North Darfur.
Together with the Sudanese Ministry of Health, MSF provides a range of free services in maternal health in Dar Zaghawa and Tawila in North Darfur, including antenatal and postnatal care, delivery services and family planning, as well as sexually transmitted infection treatment and counselling.
As an independent and neutral medical aid agency, MSF serves people based on medical need only, regardless of their tribe, race, religion or political affiliation. Since 1979, MSF Sudanese and international staff, together with the Ministry of Health, have been providing medical assistance to the people of Sudan suffering from the effects of poor access to health care, natural disasters, nutritional crises, epidemics and armed conflict. Some of the services offered by MSF include reproductive healthcare, kala azar treatment, counselling services, and nutritional, pediatric and emergency obstetric care. MSF is running medical activities in health facilities in Tabarak Allah in Al-Gedaref state and Azaza Damous in Sennar state; in Tawila, Kaguro and Dar Zaghawa in North Darfur state.
*The patient’s name has been changed to protect her privacy.