Post on 26-Dec-2015
Childbirth is like a
WAR
LIVE or DIE?Access to
Maternal Health in
South SudanKhalifa Elmusharaf1,2,3,4, Diarmuid O'Donovan2, 3
1. University of Medical sciences & Technology, Khartoum, Sudan2. National University of Ireland Galway3. Connecting health Research in Africa & Ireland Consortium (ChRAIC)4. Royal College of Surgeons in Ireland
Content
•Context•Research challenges•Methodology•Findings•Final remarks
Acknowledgement:This project is funded by Connecting Health Research in Africa and Ireland Consortium (CHRAIC), Irish Aid, Global Health through Education, Training and Service (GHETS), and University of Medical Sciences & Technology (UMST).
South Sudan 50Years of war
8Million population
2Million died
4Million displaced
‘05 Peace agreement
‘11 Independence
South Sudan Maternal health indicators
MMR : 2054 per 100,000 live births
10 % delivered by Skilled Birth Attendants
Accessibility to Emergency Obstetric Care is low as indicated by
Caesarean Section rate of 2%
23% get ANC by any qualified personnel
(SHHS, 2006)
Girls in South Sudan are more
likely to die in pregnancy and childbirth than to finish primary school
(UNFPA 2006)
However, very low utilization of accessible maternal health care facilities in South Sudan is one of the major obstacles to improve maternal survival,
....which is much influence by DEMAND side barriers.
Most of the efforts of Health System including International and National NGOs have been done to
reduce SUPPLY side barriers
USAID, 2007: “Most of the attention is focused at the
facility level -- waiting for clients to come into the facility, and the facilities appear to be underutilized.”
Health System ??
Health System: Let us build more hospitals Let us train more doctors people are dying over there.
Recent survey found that development agents in post conflict settings seem (CDA 2011):
• not to take time to understand the context adequately• not to share their respective analysis• not to translate their context understanding into programming • not to be flexible to adjust programming in the light of changes
Recent survey found that development agents in post conflict settings seem (CDA 2011):
• not to take time to understand the context adequately• not to share their respective analysis• not to translate their context understanding into programming • not to be flexible to adjust programming in the light of changes
• lack of understanding of the context • lack of statistics and planning data• limited capacity and experience• bypass the government in the delivery of basic services.
(Sabuni 2011)
South Sudan
Finding from South Sudan indicated that the programs of the development agents are significantly hampered because of the:
Research Methodology challenges
TRUST
Trust
Illiteracy
competition
ComplexityOvercome the lack of trust and
sensitive issues
– A lack of mutual trust between the researcher (outsider) and the respondents remains the main challenge to obtain reliable information.
Research challenges
ILLITERACY
Trust
Illiteracy
competition
Complexity
Increase community readiness
– Power differences between researcher and participant–The researcher alone contributes the thinking that goes into the project, and the subjects contribute the contents to be studied.
Research challenges
COMPETITION
Trust
Illiteracy
competition
Complexity
Engage communities
– Competing with NGOs that provide services and Food
– Lack of motivation to participate in any research (low response rate)
Research challenges
COMPLEXITY
Trust
Illiteracy
competition
Complexity
Listen to hard to reach population
– Complexity of social institutions and cultures in which behaviour is contextualized.
Research challenges
Methodology
3. Stakeholder interviews
4. Participatory Action Research
1. Participatory Ethnographic Evaluation & Research
Renk County – Upper Nile State – South Sudan 2008 - 2012
2. Critical Analysis Technique
Participatory Ethnographic Evaluation & Research PEER
PEER is an innovative, rapid, participatory and qualitative research method involving ordinary members of the community to generate in-depth and contextual data
( Price and Hawkins 2002).
Research & Empowerment
1. PEER
14 marginalized women with no formal education were recruited by village leaders
PEER
The women attended 4 days PEER training workshop to develop their skills to:
• Design research instruments• Conduct interviews• Collect narratives and stories • Analyse the data
PEER
Discussed important maternal health issues in their community.1
PEER training workshop
Identified key themes and questions for the qualitative research 2Developed images to remind them with the questions. 3
3
PEER training workshop
Qualitative Researcher
PEER
They returned to their villages to carry out in-depth interviews with three of their friendsover three weeks
Research team visited them to collect their findings in a series of debriefing sessions
De-briefing with PEER researchers
Upon completion of the interviews with peers, the women came together with researchers, for analysis workshop
Discuss main themes from their interviews
Act out Dramas
PEER Analysis workshop
Develop profile stories
Advance analysis NVivo
2. Critical Incident Technique We conducted in-depth interviews with All possible witnesses of the critical case (Death or near miss) whether the:
• Husband• Mother• in-laws• Sisters• TBA• midwives • woman herself
(in cases of survival)
Governor of Renk county
Executive Director of Renk county
Humanitarian Aid Commissioner
Background3. Stakeholder interviewsPolicy makers
Preventive DepartmentHIV/AIDS DepartmentMidwifery SchoolMedical Director of Renk Hospital
Women Organization for Development and Capacity BuildingMubadirroon organization for prevention of disaster & war impactMercy Corps.Turath Organization for Human Development
Churches Mosques Tribal Chiefs
Planners providers
NGOs Community Leaders
4. Participatory Action ResearchDiagnosis of the
problem
Action planning
Taking action
Evaluation
StakeholdersPEER
Prioritized maternal health issues
PEER educational materialsSH project proposals
PEER materials community, SH proposals PEER
Some of the Findings
The years of war resulted in fear and instability.
People are concerned about:• Protecting their property
• Preparing for upcoming unpredicted war
• Compensating for the men they lost in the war by having more children.
ServicesServices
WillingnessWillingness AbilityAbility
CostCost
Community involvementCommunity involvement
Utilization of serviceUtilization of service
Knowledge & awareness
Knowledge & awareness
CultureCulture
BeliefsBeliefs
Making the decision Reaching the health facility Receiving services
Access to maternal health careAccess to maternal health care
Demand-Side barriers Supply-Side barriers
AcceptabilityAcceptability
AffordabilityAffordabilityOutcomeOutcome ProcessProcess
StructureStructure
Geographical distribution
Geographical distributionFinancingFinancing
AvailabilityAvailability
QualityQuality
TransportationTransportation
SecuritySecurity
TimeTime
AccessibilityAccessibility
Preparedness
Bad pregnancy
Bad labour
No Money
No transportation
DeathPast experiences
Financial inability Circle of fears
Bad pregnancyHeavy work
Not eating well
Lack of follow up
Stress and bad emotions
Bad relation with husband
Bad labourNeglect & carelessness
Wrong advices
Not competent birth attendants
Inaccessible care
Non functioning facilities
Alone in the field
Alone at home
At home with TBA
At home with VM
On the way
Hospital
Places of delivery
“God and herself”
Alone in the field
Alone at home
At home with TBA
At home with VM
On the way
Hospital
No money
Hospital is far
Neighbours encouragement
Habit
Experienced
Healthy
Places of delivery
Alone in the field
Alone at home
At home with TBA
At home with VM
On the way
Hospital
Places of delivery
Afford it
Complications
Prolonged labour
Difficult labour
Making the decision Reaching the health facility Receiving services
Access to maternal health careAccess to maternal health care
Demand-Side barriers Supply-Side barriers
Perceived need
Social determinants
AcceptabilityAcceptabilityAffordabilityAffordability AvailabilityAvailabilityQualityQualityAccessibilityAccessibility
Take decision
Funds
Vehicle
Negotiate the price
Quality of the road
Distance
Reaching the facility
Zigzagging pathway
Ajak zigzaged between two health providers. Each one refers her to the other one after failing to manage the labour, without taking a decision to refer her to an appropriate facility.
Referral to more than one facility
Patient visits several health care facilities before reaching the appropriate facility that provide comprehensive emergency obstetric care.
Bypassing the non-functioning facilities
However, bypassing the non-functioning facilities is one of the patterns that were noticed within the survivors when women with prolonged labour or bleeding survived because of bypassing non-functioning facilities and referred directly to the referral functioning Hospital.
Making the decision Reaching the health facility Receiving services
Access to maternal health careAccess to maternal health care
Demand-Side barriers Supply-Side barriers
Perceived need
Social determinants
Non functioning facilities
Non competent providers
AcceptabilityAcceptabilityAffordabilityAffordability AvailabilityAvailabilityQualityQualityAccessibilityAccessibility
AppropriateAppropriate
Remarks
The value of the
social cohesion,
the importance of
supporting each other,
facing and solving problems
are deeply rooted in the culture of
south Sudan and
play a major role
in preventing many
maternal deaths
No facility is better than
non functioning facility
&
No provider is better than
non comptent provider
A non functioning facility kills
A non competent provider kills