Childbirth is like a WAR LIVE or DIE ?

1. Childbirth is like a WAR LIVEor DIE? Access to Maternal Health in South Sudan Khalifa Elmusharaf1,2,3,4,Diarmuid O'Donovan2, 3 • University of Medical sciences & Technology, Khartoum, Sudan • National University of Ireland Galway • Connecting health Research in Africa & Ireland Consortium (ChRAIC) • Royal College of Surgeons in Ireland

2. Context • Research challenges • Methodology • Findings • Final remarks Content 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).

3. South Sudan 50Years of war 8Million population 2Million died 4Million displaced ‘05Peace agreement ‘11Independence

4. indicators South Sudan Maternal health (SHHS, 2006) MMR : 2054per 100,000 live births 10 %delivered by Skilled Birth Attendants 23%get ANCby any qualified personnel Accessibility to Emergency Obstetric Care is low as indicated by Caesarean Section rate of2%

5. Girls in South Sudan are more likely to diein pregnancy and childbirth than to finish primary school (UNFPA 2006)

6. Most of the efforts of Health System including International and National NGOs have been done to reduce SUPPLYside barriers USAID, 2007: “Most of the attention is focused at the facility level -- waitingfor clients to come into the facility, and the facilities appear to be underutilized.” However, very low utilization of accessiblematernal health care facilities in South Sudan is one of the major obstacles to improve maternal survival, ....which is much influence by DEMANDside barriers.

7. ?? 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 • notto translate their context understanding into programming • not to be flexible to adjust programming in the light of changes

8. Finding from South Sudan indicated that the programs of the development agents are significantly hampered because of the: South Sudan • 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)

9. Research Methodology challenges

10. Research challenges • A lack of mutual trust between the researcher (outsider) and the respondents remains the main challenge to obtain reliable information. Trust Illiteracy TRUST competition Complexity Overcome the lack of trust and sensitive issues

11. Research challenges • 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. Trust Illiteracy ILLITERACY competition Complexity Increase community readiness

12. Research challenges Trust • Competing with NGOs that provide services and Food • Lack of motivation to participate in any research (low response rate) Illiteracy COMPETITION competition Complexity Engage communities

13. Research challenges Trust • Complexity of social institutions and cultures in which behaviour is contextualized. Illiteracy COMPLEXITY competition Complexity Listen to hard to reach population

14. Methodology 1. Participatory Ethnographic Evaluation & Research 2. Critical Analysis Technique 3. Stakeholder interviews 4. Participatory Action Research Renk County – Upper Nile State – South Sudan 2008 - 2012

15. 1. PEER PEER Participatory Ethnographic Evaluation & Research Research & Empowerment 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).

16. PEER 14 marginalized women with no formal education were recruited by village leaders

17. 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

18. PEER training workshop 1 Discussed important maternal health issues in their community. 2 Identified key themes and questions for the qualitative research 3 Developed images to remind them with the questions.

19. PEER training workshop 3

20. PEER Qualitative Researcher

21. They returned to their villages to carry out in-depth interviews with three of their friends over three weeks

22. De-briefing with PEER researchers • Research team visited them to collect their findings in a series of debriefing sessions

23. PEER Analysis workshop Discuss main themes from their interviews Upon completion of the interviews with peers, the women came together with researchers, for analysis workshop Act out Dramas Develop profile stories Advance analysis NVivo

24. 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)

25. 3. Stakeholder interviews Background Policy makers Planners providers NGOs Community Leaders • Churches • Mosques • Tribal Chiefs • Women Organization for Development and Capacity Building • Mubadirroonorganization for prevention of disaster & war impact • Mercy Corps. • Turath Organization for Human Development • Governor of Renk county • Executive Director of Renk county • Humanitarian Aid Commissioner • Preventive Department • HIV/AIDS Department • Midwifery School • Medical Director of Renk Hospital

26. PEER Stakeholders 4. Participatory Action Research Prioritized maternal health issues PEER  educational materials SH  project proposals PEER  materials  community, SH  proposals  PEER

27. Some of the Findings

28. 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.

29. Demand-Side barriers Making the decision Reaching the health facility Receiving services Supply-Side barriers Access to maternal health care Community involvement Beliefs Availability Geographical distribution Security Acceptability Financing Culture Services Utilization of service Knowledge & awareness Accessibility Structure Time Quality Affordability Cost Process Outcome Transportation Ability Willingness

30. Circle of fears

31. Bad pregnancy

32. Bad labour

33. Places of delivery “God and herself”

34. Places of delivery

35. Places of delivery

36. Making the decision Reaching the health facility Receiving services Demand-Side barriers Supply-Side barriers Access to maternal health care Perceived need Social determinants Accessibility Affordability Acceptability Quality Availability

37. Reaching the facility

38. Zigzagging pathway Ajakzigzagedbetween 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.

39. Referral to more than one facility Patient visits several health care facilities before reaching the appropriate facility that provide comprehensive emergency obstetric care.

40. 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.

41. Making the decision Reaching the health facility Receiving services Demand-Side barriers Supply-Side barriers Access to maternal health care Appropriate Perceived need Non functioning facilities Social determinants Non competent providers Accessibility Affordability Acceptability Quality Availability

42. Remarks

43. The value of the social cohesion, the importance of supporting each other, facing and solvingproblems are deeply rooted in the culture of south Sudan and play a major role in preventing many maternal deaths

44. No facility is better than non functioning facility & No provider is better than non comptent provider Anon functioning facilitykills Anon competent providerkills

45. Thank You! شكراً