(Babker El Shiek and Anke van der Kwaak) - Sudan has high maternal mortality. The rate among nomads - groups of people
who move from place to place as a way of obtaining food, finding pasture or make a living - is very high and varies between different regions of the country. The objective of the study is to identify the factors affecting the utilization of maternal health care services by nomadic communities in Sudan, to make recommendations to improve their health. Nomadic health practices and health care services are the main influencing factors affecting the utilization of maternal health care services. Nomadic health practices are influenced by the mobile lifestyle of nomads, their low level of education and knowledge, gender norms, beliefs, values and attitudes, and their geographical locations. Existing health care services are ill-adapted to the nomadic lifestyle. The study also demonstrates some best practices from other countries that can be applied to the nomadic context in Sudan, such as community health workers, training and support for traditional birth attendants, provision of joint mobile health services for humans and livestock and the establishment of maternity or birth waiting homes. Since the utilization of maternal health care services by nomads is extremely low, the study recommends evidence-based strategies to increase community demand for services or bring women closer to emergency obstetric services
The nomads of Sudan are concentrated in the western part of the country, namely in Darfur and Kordofan regions. The state of South Darfur (now the states of South and East Darfur) has the bulk of the nomads (58.2 %), while 19.6 % live in the states of North and South Kordofan. There are about 16.1 % in eastern Sudan in the states of Kassala and Red Sea. The remaining populations of nomads are spread over other states in smaller numbers (Ali 2008; Ahmed and Abdel-Rahman 2008).
Sudan has poor sexual and reproductive health indicators. The maternal mortality ratio (MMR) is estimated at 360 maternal deaths per 100,000 live births and has only decreased by 50 % between 1990 and 2013 (WHO et al. 2014). The risk of adult women dying from pregnancy- and childbirth-related causes is 1 in 60 (WHO et al. 2014). In 2013, the proportion of deliveries attended by trained personnel was about 30 % (WHO 2014a). The proportion of institutional delivery is extremely low (20 %) because the common practice is home delivery, even in urban areas (Federal Ministry of Health 2011).
The maternal health status of nomads is even worse, as a census of Sudan in 2008 reveals very high maternal mortality among nomads. It is estimated that the MMR is as high as 503 maternal deaths per 100,000 live births (Alnoory 2008; Ahmed and Abdel-Rahman 2008). The high MMR among nomads is due to a number of reasons. Nomads encounter challenges in accessing and utilizing the services of trained midwives or other skilled maternal health service providers. The cultural beliefs of nomads, such as the number of children born in a family being a symbol of its position in the community, indicate little use of family planning methods (Montavon et al. 2013). This has a direct correlation to maternal mortality and morbidity, unless pregnancies are well spaced. Other cultural practices such as widespread practices of female genital mutilation (FGM) and early marriage are also contributing to high maternal mortality. In addition, other reasons for high maternal mortality include i) misconceptions and practices related to nutrition, maternal diet and maternal care; ii) limited access to health care services; and iii) low rates of enrolment in formal education (Schelling et al. 2003; Schelling et al. 2005; Montavon et al. 2013).
Given these statistics, there is a need to better understand the factors that influence the status of nomadic maternal health; therefore, this study focuses on maternal health among the nomadic communities of Sudan. It will analyse different factors that influence the utilization of maternal health care services by nomads, and, citing success from similar contexts, it will provide suggestions and recommendations to improve utilization.
Sudan covers an area of 1,882,000 km2 in the north-east of Africa between 15°00?N and 30°00?E. Sudan borders Egypt, Libya, Chad, the Central Africa Republic, South Sudan, Ethiopia and Eretria (UNDP 2013). The total population of Sudan was estimated at 37,289,406 in 2014, with 63 % of people living in rural areas (Sudan Central Bureau of Statistics 2013).
Geographically, the terrain of Sudan consists of flat plains and mountains. The Blue and White Niles meet at Khartoum to establish the great Nile river which runs towards the north before crossing the border with Egypt (Anon 2014). Sudan’s climate consists of an arid zone in the north (Nubian Desert) as a continuation of the great desert, and a tropical zone in the south and south-west (Anon 2014). The existence of different climates and the presence of the Red Sea and large numbers of mountains have led to variations in the density of rainfall, temperatures, types of soil and the topography. These factors play an important role in determining the types and distribution of plants and pasture. In addition, the availability of pastoral land is an important factor determining the distribution and location of different nomadic groups across the country.
With an MMR of 360 maternal deaths per 100,000 live births, Sudan is ranked as one of the countries with the highest maternal mortality in the world. For every maternal death, 20 women or more may develop delivery- or birth-related complications or disabilities (Abdel-Tawab and El Rabbat 2010). Direct causes of maternal death in Sudan are the same as in other sub-Saharan countries, including haemorrhage, eclampsia, sepsis, unsafe abortion and obstructed labour (WHO et al. 2014; Ahmed et al. 2012). The major indirect causes are anaemia, malaria and hepatitis (Dafallah et al. 2003; Ahmed et al. 2012). Sudan’s census shows that the MMR among nomads is very high, at 503 maternal deaths per 100,000 live births, with regional disparities. The highest values of MMR are reported in the western part of the country (Darfur and Kordofan) (Ahmed and Abdel-Rahman 2008). The high MMR among nomads suggests gaps in accessing good-quality maternal health care services and poor health practices.
Three quarters (74 %) of pregnant women undertake one antenatal care (ANC) visit, while 47 % undertake four visits. This may be an indication of a low quality of service from the clients’ perspective (Federal Ministry of Health 2011). Utilization of ANC services in Sudan is influenced by a number of factors. The mothers’ level of education has a direct positive relation with utilization of the services, and utilization of ANC in urban areas is five times higher than that in rural areas (Ibnouf et al. 2007). The distance to health facilities and perceived quality of ANC also contribute to the utilization of services (Ali et al. 2010; Ibnouf et al. 2007). The Sudan Household Survey (SHHS) shows a very low proportion of institutional delivery (20 %). This is because Sudanese culture encourages delivery at home in the presence of a trained midwife or traditional birth attendant (TBA), rather than facility-based delivery (Mohamed and Boctor 2009). Sudanese women perceive delivery at health facilities as meaning that they are unable to deliver normally. Delivery at home, where there is no means of reliable transportation, may lead to maternal death in cases of emergency; furthermore, obstructed labour during home delivery is a known cause of fistula in Sudan (Mohamed and Boctor 2009; Khalil 2011).
Obstetric fistula is a serious, devastating and humiliating condition that results from prolonged labour (WHO 2014b; Mohamed and Boctor 2009). In the majority of cases, fistula develops because the delivery is conducted at home and attended by unskilled personnel (Mohamed and Boctor 2009). In Sudan, almost half of fistula cases are in the western part of the country, where the majority of nomads live (Mohamed and Boctor 2009; Khalil 2011). The development of fistula is influenced by socio-cultural factors such as FGM, early teen pregnancy, low level of education, poverty, malnutrition and a poor health system (Mohamed and Boctor 2009; Khalil 2011; WHO 2014b).
Findings from the 2010 SHHS reveal poor family planning indicators. The survey indicated that only 9 % of women used family planning methods, and the unmet need for contraceptive was 29 % (Federal Ministry of Health 2011). A review of literature (Ali and Okud 2013; Ahmed 2013; Brair and Eltayeb 2013) reveals that utilization of family planning in Sudan is influenced by many factors, with the level of education of women and their husbands and religious beliefs the most influential (Ali and Okud 2013). Women’s low level of interest in family planning can be related to religious ideology; in Islamic countries, childbirth is always perceived as a natural practice. Therefore, the majority of Sudanese women consider family planning methods taboo (Serizawa et al. 2014).
In conclusion, the utilization of maternal health care services by nomads in Sudan is extremely low. There are many factors influencing utilization; in general, they are the same as in other nomadic areas in Africa. They include individual characteristics such as age; children and adolescents are exposed to maternal health issues such as FGM, early marriage and teen pregnancy. Utilization of services is also affected by low levels of education and health awareness. The mobile lifestyle of nomads and gender inequality also act as major challenges that restrict women’s utilization of maternal health care services. Although nomads can afford the cost of services, their willingness to pay cannot be judged. The limited availability of health facilities and health staff at the community level is a crucial factor that restricts nomadic women’s access to health care services.
Finally, the utilization of health care services is influenced by nomads’ perceived health needs, which are based on the beliefs, values and traditions that are central to the fabric of their society in Sudan.
Based on the findings and conclusions, the study recommends evidence-based strategies and interventions to improve the utilization of maternal health care services by nomads. The recommended strategies aim either to increase community demand for maternal health care services or bring women closer to emergency obstetric services. The following recommendations are proposed at policy, service-delivery and community levels:
The government should include nomadic CHWs and nomadic village midwives within existing human resources for health strategic policy and develop curricula for basic and in-service training programmes.
The government should develop a national policy on the management and oversight of traditional medicine.
State Ministries of Health should increase coverage of services for nomads by adopting the mobile-clinic approach.
State Ministries of Health should train and deploy nomadic CHWs and nomadic village midwives to improve the utilization of maternal health care services.
State Ministries of Health can adapt the MWH intervention to improve the utilization of maternal health care services.
State Ministries of Health should sensitize and train health staff at fixed health facilities on nomads’ special needs.
State Ministries of Health should improve the quality of maternal health care services by improving the provision of essential equipment, instruments and supplies.
State Ministries of Health should distribute human and financial resources equally between rural and urban areas.
Social networks of nomadic women should be established to promote the utilization of services and empower women.
Health awareness campaigns should be conducted at the community level to raise nomads’ level of awareness about the importance of maternal health.
An advocacy group comprising tribal, religious and community leaders should be established to advocate for better utilization of maternal health care services.