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

Thank You!

شكرا