Hamashkoreb, Kassala State, April 4, 2013- A group of 44 young women gather around a wooden bench in their small classroom as their teacher demonstrates how to safely deliver a baby. The student’s faces shine underneath their dazzling white cloth toub uniforms. Welcome to the first midwifery school of Hamashkoreb, a village in Eastern Sudan known for its high rate of maternal death.
The students call out tips so the teacher doesn’t forget a step as she patiently “delivers” a cloth doll. The students, all mothers themselves, are fully engaged and aware of the need to sanitize and cleanse during each step to ensure a safe delivery for both the mother and her child. Yet maternal care was not always considered so carefully in this village.
“We chose to get training as midwives because our young mothers were dying every day. Our villages became famous on the radio for our huge rate of maternal death and we wanted to do something to change that,” says Fatma, one of the students.
A small traditional village situated on the border with Eritrea, Hamashkoreb is isolated from the bustling oasis city of Kassala located 250 km to the south. Until recently the road to Kassala City was unpaved requiring sick patients to travel for up to two days to reach the hospital. A woman suffering from an emergency situation during delivery would not survive the two-day trip to the capital city.
As recently as 2006, the Sudan Household Survey data found that women in Kassala State suffered roughly 1,400 deaths out of 100,000 live births – the highest rate in Africa and one of the highest in the developing world. A study completed in 2010 showed that the maternal death rate was lower.
Learning lifesaving techniques
“We used to think that these deaths were part of destiny and Allah’s will,” says Adam Talab, chief of the Hamashkoreb village. “We still know that we can’t reject God’s will, but now we know that a lot of the times these deaths were caused by our negligence as a community.”
Hamashkoreb is one of several communities in Sudan that is slowly developing a health care program for women. The village is benefitting from a Multi Donor Trust Fund National (MDTF-N) project aimed at increasing access to basic health services by poor communities in Sudan’s war-affected states of Kassala, South Kordofan, Blue Nile, and Red Sea. The program serves a population of approximately 5.1 million.
Supported by the DHSDP, the local government trains midwives on how to follow-up women during their pregnancy and spot a pregnancy in trouble before the woman is in labor, safely and hygienically deliver a baby, and follow-up with the mother and child after delivery. In the Hamashkoreb region, a total of 66 midwives have successfully completed their one-year training program (26 graduated in 2009 and 40 in 2011). One midwifery school has been built in each program state, and six rural hospitals have been rehabilitated or built. An additional 2,240 health care workers have been trained and are providing basic health services to rural communities in the four states.
Paving the Way
Mohamed Osman Hamid, DHSDP federal project coordinator, Federal Ministry of Health, says the government chose to run the pilot in Hamashkoreb precisely because the village had the highest maternal death rate in the country.
The decision to build the midwifery schools in the villages came after a survey conducted with technical assistance from the World Bank revealed that women weren’t allowed to go alone to the nearby city of Kassala to attend midwife classes. With the input from the community, the decision was made to bring the schools to the villages, Hamid says.
He calls the midwifery pilot in Hamashkoreb a success because the families, mayors, and state leaders all supported the project. “All 17 states in Sudan have now requested midwife training,” Hamid says.
The midwives are paid an incentive against performance, including the 1st antenatal care consultancy and assisted delivery plus post-natal consultancy. This helps achieve the project’s primary goal: to prevent maternal deaths by sending high risk patients to a hospital where they can be treated by obstetricians trained in emergency care, says Hamid.
“Before the midwives school was established, all of the women who needed Cesarean births would die immediately and be buried on the spot,” says Chief Talab.
“Our teacher Shadiya worked really hard and spoke to the men in our village about owning up to our responsibilities as a community towards these deaths and about trying to find ways to save our young mothers from dying during delivery,” says Fatma, one of the students.
Trained in basic neonatal care, each midwife receives a delivery kit packed with very basic medicines and drugs which insures basic hygiene for a normal delivery. The midwives can’t perform high risk deliveries but can still identify high blood pressure, swollen legs, and other ailments simply by observing the symptoms.
“I now know when a baby is correctly positioned, when a mother needs a cesarean section, when she will be okay in a home delivery. I know how to sanitize and sterilize my tools using boiling water and cotton,” Fatma explains. “I am also taught how to take care of the newborn if they begin choking during delivery.”
Traditionally a pregnant woman would hide her condition until she was ready for delivery, making it difficult to teach her how to care about her newborn baby. This also made it difficult for the midwives to follow up on a new mother’s health with a home visit.
Today, the number of women who see a trained health worker while pregnant has grown from 48% in 2009 to 69% in 2012 (in all four target states). Previously, just 19% of live births were delivered by a trained midwife; today that figure is 51%.
With its partner, the Sudan Ministry of Health, the DHSDP also teaches women basic nursing and first aid skills. Trained nurses travelled from the hospital in Kassala City to Hamashkoreb to teach the midwives how to connect a medicine drip, properly inject medicines, care for a wound, and other basic skills. Now 27 women in the village are both trained nurses and midwives.
“In some cases the closest hospital is 500 km away, and many families cannot afford to send a woman to the hospital for delivery in case of an emergency. For these reasons, if you want to save lives you have to give technical skills to the people in the communities,” says Isabel Soares, Senior Operations Officer for the MDTF-N at the World Bank. “This kind of training allows the women who have life threatening trouble to be identified and then evacuated to a hospital,” Soares adds.
With its focus on improving women’s health, the DHSDP has had a significant impact on the way the women perceive themselves within their communities. Ahmed Bitay, the Hamashkoreb Commissioner, says the pilot program created great opportunities for women in the villages, including motivating them to learn how to read. “The midwives, during their regular house visits, talk to the mothers about the importance of adult literacy for women, and we have around 400 women that have attended Quranic schools and can recite the whole of the Quran now,” Bitaya says. According to him, the midwives also helped non-profit organizations (NGOs) gain the trust of the community.
The federal government wants to incorporate the midwife training program for underserved areas into its country-wide health system, ensuring that the midwife training program will continue once support from the DHSDP comes to an end. “The country will need an additional 13,028 midwives by 2015 to ensure that every pregnant woman has the option to deliver her baby with the help of a skilled midwife,” says Mohamed Osman Hamid, DHSDP project coordinator for the federal Ministry of Health. The Ministry of Finance has already set aside 37 million SDG (~ US 15 million) to fund the training of midwives over a one-year period, he adds.
Back in Hamashkoreb, Madina, a midwife student, says that there is nothing more rewarding than having the knowledge to save lives. “We want to save our communities from the loss of life due to ignorance; we now know how important it is to know how to protect our pregnant women,” Madina says.
The Decentralized Health System Development Project is one of 15 projects funded by the Multi-Donor Trust Fund-National (MDTF-N). The MDTF-N is a means for countries to contribute to the reconstruction and development needs of war-torn areas of Sudan. The MDTF-N ends on December 30, 2013.