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Improving Maternal and Neonatal Health in Kassala State: Strengthening Primary Health Care & Community Mobilization in Kassala Town and Rural Kassala Localities. Baseline Surveys Monograph

Improving Maternal and Neonatal Health in Kassala State: Strengthening Primary Health Care & Community Mobilization in Kassala Town and Rural Kassala Localities. Baseline Surveys Monograph






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    Improving Maternal and Neonatal Health in Kassala State: Strengthening Primary Health Care & Community Mobilization in Kassala Town and Rural Kassala Localities. Baseline Surveys Monograph Improving Maternal and Neonatal Health in Kassala State: Strengthening Primary Health Care & Community Mobilization in Kassala Town and Rural Kassala Localities. Baseline Surveys Monograph Presentation Transcript

    • Improving Maternal and Neonatal Health in Kassala State:Strengthening Primary Health Care and Community Mobilization in Kassala Town and Rural Kassala Localities
    • Improving Maternal and Neonatal Health in Kassala State:Strengthening Primary Health Care and Community Mobilization in Kassala Town and Rural Kassala Localities Project funded by Italian Co-operation Implemented by UNFPA, AUW and SMoH Research monograph of baseline surveys in two localities: Community baseline survey of women’s KAP on RH issues VMWs baseline KAP survey on RH issues Prepared by: Dr. Dina M. Sami Khalifa MBBS,MSc Dr. Nafisa M. Bedri PhD Dec. 2012
    • LIST OF CONTENTSIntroduction 4Project objectives 4 Baseline survey on KAP of all VMWS in Kassala state 13Baseline survey on KAP of women in communities 5 Objectives 13of the two targeted localities Methodology 13Objectives 5Methodology 5 Results 14 Demographic characteristics and work experience 14Results 7 Knowledge on danger signs during pregnancy, 15General demographic characteristics of sampled women 7 labour and puerperiumANC Experience 7 ANC practices (skills) 16Family planning experience 8 Delivery and post-delivery practices (skills) 16Knowledge on danger signs during pregnancy 9 Hygiene practices 16Knowledge on danger signs during labor 10 Role in birthing plans 17Knowledge on danger signs during puerperium 10Knowledge on danger signs for newborns 10 Conclusion 18Knowledge on HIV/AIDS 11Birth experience and birthing plans 11 Recommendations & way forward 19
    • INTRODUCTIONProject objectives:The overall goal of the project is to contribute to im- d) Developing a generalizable and replicableproving the health and wellbeing of mothers, new- model that enhances reproductive health (RH) ser-borns and their families in two localities in Kassala vices to address MDG 5 and MDG 4 through thoroughstate, Kassala town and rural Kassala. documentation and monitoring of the implementa- tion process, use of evidence-based interventionsSpecific objectives of the project include the follow- and taking into account lessons learned.ing:1. Improving the quality and uptake of maternal 2. Contributing to ensuring that all pregnant wom-and neonatal health care in 19 health facilities and en and their newborns in the two localities are caredsurrounding communities. This will be accomplished for by a trained health worker during pregnancy andthrough: childbirth. This will be done through provision of im-a) Development of an assessment framework proved health care at community and primary healthfor a rapid baseline assessment of existing local Pri- care levels, backed up by a functioning referral sys-mary Health Care Units (PHCUs). tem.b) Building the capacity of the PHCUs, i.e. im-proving the competency of relevant health cadres To assess the community baseline status, two surveysthrough a series of in-service trainings and refurbish- were conducted; a KAP survey among communitying and equipping health facilities. women and a KAP survey among all registered VMWsc) Sensitizing and organizing the communities to in Kassala state.take an active part and support the sustainability ofthe project interventions.4
    • BASELINE SURVEY ON KAP OF WOMEN IN COMMUNITIES OF THE TWO TARGETED LOCALITIES1. OBJECTIVES Therefore, both localities acted as one target popu-To assess the knowledge, attitudes and practice (KAP) lation, but differences in the average size of house-of women in the community regarding various RH is- holds between the localities had to be considered insues (use and knowledge of FP methods, pregnancy the sampling procedure.danger signs, opinion on home delivery versus facil-ity delivery, birthing plans, HIV/AIDS and opinions The two localities are significantly different in termson midwives’ capabilities). The target women were of the number of households, so the total sample wasmothers with a delivery event not more than 5 years divided between the two localities proportionally toago. size (PPS).2. METHODOLOGY • Sampling within each locality was multi-stage sam-• Study population: Women of reproductive age in pling:the two localities who had a pregnancy experience 1. From the catchment villages, the 10 most popu-during the past 5 years. lated villages in each locality were chosen, and from• Sample size: 800 women, 500 from rural Kassala these, 5 villages were chosen randomly (primaryand 300 from Kassala town. sampling units).• Sampling methodology: Both localities, although 2. Since the 10 villages in each locality are not equalclassified as urban and rural, are considered similar in size, the 5 chosen villages were selected using PPS.(in terms of demographic and household characteris- To do that, the cumulative frequency of number oftic features) and the comparison was within the state, households of the 10 villages in each locality was cal-not between states (i.e. no clustering features). culated. Then, random numbers using the number 5
    • of digits equivalent to the total number of households themselves or via interview. The questions are spreadto be sampled were obtained from tables of random over five sections. Options included both open andnumbers (not computerized tables). The villages con- closed questions. Responses to the questions did nottaining the random numbers were the villages from contain long recall periods but concentrated mostlywhich samples were taken. on current practices. The questions were easy, non- threatening and not sensitive. They started off with3. Then, an equal number of households with 1 wom- simple demographic questions about the sampledan/household (secondary or main sampling units) women. Then the questionnaire explored the RH ser-were selected from the chosen villages by simple vices the women received during their pregnanciesrandom sampling (SRS) (or using methods the ground (ANC, birth, abortion care and FP). Then their knowl-team found more feasible). edge of various RH topics was explored (FP, danger signs, birth planning).• Response rate: 90%. • Quality assurance: Interviewers were chosen• Data collection tool: A questionnaire was de- according to significant past experience of conduct-veloped by the AUW team to be filled in by trained ing interviews. 10 interviewers were chosen and re-interviewers. Interviewers were recruited and trained ceived one week’s training before the survey. Pretest-to interview the target women. A pretest was per- ing of the questionnaire was done on a sample offormed on a sample of 100 households. Data collec- 50 households and necessary changes were made ac-tion commenced on 23rd Dec 2011 and concluded on cordingly. The following points were assessed in the7th Jan 2012. pretest:• Questionnaire design: The questionnaire waswritten in Arabic. The questionnaire was long but sim- • Whether or not the respondents understoodple, and could be administered by the respondents the questions as intended6
    • • How respondents reacted to some questions have at least one female of reproductive age (SHHS perceived as sensitive 2012). 60% of them have had at least one birth,• Whether questions were in logical order and 35% of them are not educated. This reflects the• Whether skip rules for the questions were importance of safe motherhood and RH issues in a correct country like Sudan. Kassala has one of the worst RH• The length of the questionnaire and childhood indicators. ANC EXPERIENCE2. RESULTS The first section of the questionnaire examined theGENERAL DEMOGRAPHIC CHARACTERISTICS OF ANC experience of the sample women and the typeSAMPLED WOMEN and quality of care they received during their lastThe questionnaire started with basic demographic pregnancy. Almost 44% of the women said they hadquestions. The sample women consisted of women of ANC during their last pregnancy in a health facilityreproductive age who have given birth at least 5 years (HF) only, while 21% had ANC both in a HF and fromago. Almost 30% of the sample were young mothers a midwife. Just 5% stated they had ANC from a VMW(less than 25 years old) and almost 70% of the sample only, mainly because it was a family tradition (98%).women had a very low level of education (illiterate or Regarding frequency of visits, 66.6 % of women statedprimary level education). Almost 60 % had a child less that they went to ANC every month during their lastthan 3 years ago, 15 % were pregnant at the time of pregnancy. A small percentage stated they receivedthe survey and 25 had a child less than 5 years ago. no ANC during their last pregnancy (2.4%), while 4.4%Therefore, the survey reflected recent rather than old had one ANC visit. 17% said they had one visit everyexperiences. Nationally, 90% of households in Sudan trimester and 10% had one visit at the beginning of 7
    • pregnancy and one towards the end of pregnancy. occurring during birth rather than during pregnancy.The subsequent questions assessed the quality of the Post partum mortality also contributes significantlyvisits they received. More than 94% of the women to MM in developing countries. According to this sur-stated that they had received good care, in terms of vey, women in Kassala state did have regular ANC vis-checking their history of previous pregnancies and its as recommended but it is clear the quality of thedeliveries, measuring blood pressure, and abdominal visits was substandard. They received services dur-examinations. 42% did not have an eye examination ing the visits that clearly are not designed to identifyfor anaemia or chest examination, 90.4% did not women who are at risk. Women, especially seen byreceive a breast examination, and 89.9% did not re- VMWs in the community, did not regularly have theirceive advice or info on HIV/AIDS prevention and test- blood and urine monitored. Also, the VMW surveying. 61% did not have their lower limbs examined for and training executed during this project highlightedoedema. 89% stated that their caregiver did request deficits in skills for BP measuring and anaemia detec-laboratory tests for urine and Haemoglobin. tion. ANC seems to be just a routine procedure and has failed to accomplish its purpose as a mechanismAntenatal care’s effect on maternal mortality has of early detection, counselling and advice.been under great debate. More and more systematicreviews of ANC in developing countries illustrate thata greater frequency of ANC visits does not necessarily FAMILY PLANNING EXPERIENCEreduce maternal mortality. They highlight the effectof the quality of the visits as more significant. ANC The second section of the questionnaire explored theshould be a means to detect women at a higher risk experience and knowledge of women regarding dif-of developing complications during pregnancy and/ ferent types of family planning methods. The typesor birth. Maternal mortality in developing countries of FP most used by the women were oral contracep-has been shown to be more obstetrical-related and tive pills (CoP & PoP) (48%).8
    • In terms of knowledge, oral contraceptive pills were maining demand for FP and to strengthen supplythe best known FP method among women (62%) fol- chain management and logistics in its health systems.lowed by breastfeeding (LAM) (56%). 82% of womendid not know about condoms as a FP method, 49% did We also need to create demand by awareness-raisingnot know about hormonal injection and 74% did not in the community with an emphasis on the benefitsknow about “safe period” as a contraceptive method. of family planning, and we need to increase access toThese results go hand in hand with SHHS 2012 that FP commodities at the community level.showed Kassala as one of the states where FP wasleast used (95.6 % of women were not using FP at thetime of the survey). KNOWLEDGE ON DANGER SIGNS DURING PREG- NANCYBased on the facility survey, the limited knowledgeand access women have to various types of family The third section of the questionnaire explored theplanning was not surprising. The FP methods most knowledge of the surveyed women regarding dangerwidely available in the targeted PHCUs were oral signs during pregnancy, labour and newborns. Thecontraceptive pills. These centres periodically lack best-known danger sign during pregnancy was vagi-supplies due to inefficient supply chain management. nal bleeding (92.5%), followed by decreased or noWhen these commodities are available, they are pro- foetal movement (79%), dizziness and/or loss of con-vided at a charge. Women have to purchase FP prod- sciousness (74%), and convulsions (74%). Suddenucts from their own pocket. generalized oedema was recognized as a danger sign by 72% of the women. Knowledge of important signsCurrently, according to the latest RHCS assessment of pre-eclampsia was low; 67% did not know that se-2007, UNFPA satisfies 12% of the country’s demand vere headaches are a danger sign, 64.3% did not knowfor family planning. MOH needs to provide the re- that severe vomiting is a danger sign, and 53.3% did 9
    • not know that blurring of vision is a danger sign. 62% KNOWLEDGE ON DANGER SIGNS DURING PUERPE-of women did not know that “burning micturition” or RIUMfluids escaping from the vagina are danger signs dur-ing pregnancy. The best-known danger signs during puerperium were severe vaginal bleeding (84%), convulsion (79%), difficulty in breathing (66%) and fever (64%).KNOWLEDGE ON DANGER SIGNS DURING LABOR The least known signs were signs of puerperal sep- sis: foul-smelling lochia (68.2%), and pus from episi-Exploring the women’s knowledge of danger signs otomy (65.6). Knowledge of signs of pre-eclampsiaduring labour revealed that the best-known danger during puerperium was also low: 70.5% did not knowsign during labour was severe vaginal bleeding af- nausea and vomiting, and 63% did not know severeter placental removal (82%), followed by delay in headaches. Knowledge of signs and symptoms ofplacental removal by more than half an hour (75%). fistula formation was low, as 56% did not know thatKnowledge of risks for precipitating vaginal fistula urine/stool incontinence is a sign.was low; 57% did not know that being in labour formore than 12 hours is a danger sign, while 48% didnot know that pushing out the baby for more than 3 KNOWLEDGE ON DANGER SIGNS FOR NEWBORNShours is a danger sign. 54% did not know that suddenloss of the feeling of bearing down during labour (a The best-known danger signs for newborns weresign for ruptured uterus) is a danger sign. slow breathing or difficulty in breathing (82%), de- creased or refusal of feeding (80%), tremors or convulsions (80%), yellow skin/eyes (62.5%) and pus from the umbilical cord stump (51%). 76% did not know that blue lips/nails are a danger sign10
    • that warrants prompt referral to a health facility. routine testing. These results are worse comparedAlso, 60% did not recognize that lower conscious- to the findings of SHHS 2010 about knowledge onness or stuperosis in a newborn is a danger sign. mother to child HIV transmission. SHHS 2010 alsoWomen in Kassala showed very modest knowledge revealed that only 2% of women in Kassala stateon various danger signs they may encounter dur- have been tested, and only 0.6% of these have ac-ing after their pregnancies. They are receiving mini- tually received their results. This indicates the press-mal information from health care providers, in this ing need to target these localities with interventionscase mostly VMWs or PHC in general. It is clear to spread knowledge and provide VCT services.that the role of PHC in providing education and dis-seminating knowledge is not met in these localities. BIRTH EXPERIENCE AND BIRTHING PLANSKNOWLEDGE ON HIV/AIDS The questionnaire explored the women’s latest birth experience and the existence of a birthing plan if they93% of the women had heard about HIV/AIDS. 22% were currently pregnant. Almost 66% had home de-did not know that the virus could be transmitted liveries in their last pregnancy and 70 % of them gavefrom an infected mother to her unborn child. 40.7% the reasons as being because they themselves insist-did not know it could be transmitted to the unborn ed to deliver at home. For women who did deliver inchild during vaginal delivery, and 53.4% did not know a health facility, the topic on which they received theit could be transmitted via breastfeeding. 83% did most advice after delivery was on breastfeeding (83%).not know that there are drugs that prevent mother The topic on which they received the least advice wasto child transmission of the virus. 43% did not on was FP (83% did not receive advice on FP), cleaningknow that pregnant women should undergo rou- episiotomy (66%) and on danger signs during pu-tine VCT for HIV, and 20% did not approve of this erperium (65%). 41% of women who were preg- 11
    • nant at the time of the survey did not have a birth- deliveries. Programmes should concentrate more oning plan. 80% of those that claimed they did have altering this mentality. Women still need to be en-a birthing plan only did so by preparing emergency couraged to have a birthing plan, especially in termsfunds. Midwives had inputs in only 30% of those of putting aside funds for emergencies during labourbirthing plans. For any future pregnancy, 60 % of or pregnancy. Women still feel satisfied with the ser-women still insisted that they preferred home de- vices of midwives. The best-known types of FP amonglivery. 86% of the women thought that their VMWs women were injections and combined pills. Womenwere capable of handling pregnancy complications. did not know the various danger signs related to ec- lampsia. Knowledge about danger signs during labourWomen in the two localities had a high rate of home de- was low compared to danger signs during puerperi-liveries, with a strong conviction in their value among um. The women showed the most knowledge regard-the mothers themselves, who insisted on doing the ing danger signs in a newborn. Knowledge on HIV/same in the future. This, coupled with the absence of AIDS was alarmingly poor. They wanted to use FP, butbirthing plans prepared by the women, is an alarming they could not have access to methods through mid-fact. Women are insisting on delivering at home with wives and had to travel to the nearest HF to get them.low access to qualified health personnel and a lackof access to nearby EMOC facilities. Interventions tar- Programmes should focus on changing the mental-geted at social and cultural beliefs should be initiated ity of women towards facility birth. We believe thatto encourage to the use of health facilities for birth. if VMWs were officially employed by nearby health facilities, women could be gradually persuadedWomen in rural and urban Kassala still believe that to deliver in facilities. More support for VMWs intheir VMW is capable of handling any emergency terms of FP methods and education on informa-that could happen to them during pregnancy or la- tion related to HIV/AIDS and training on knowl-bour, and the women still have a preference for home edge transfer to women during ANC is also needed.12
    • BASELINE SURVEY ON KAP OF ALL VMWS IN KASSALA STATE1. OBJECTIVES • Questionnaire design: The questionnaire wasGeneral objective: To assess the knowledge, atti- written in Arabic. The questionnaire was long but sim-tudes and practices of VMWs in the community on ple, and could be administered by the respondentsvarious RH issues (knowledge and distribution of FP themselves or via interview. The question was distrib-methods, pregnancy danger signs, delivery emer- uted into five sections. Options included both opengency procedures and referral mechanisms, opinion and closed questions. Responses to the questions didon home delivery versus facility delivery, birthing not contain long recall periods but concentrated onplans, HIV/AIDS and pregnancy, training and support mostly on current practices. The questions were easy,requirements, decision-making capabilities). The tar- non-threatening and not sensitive. They started offget midwives were all working in rural Kassala and with simple demographic questions, then moved toKassala town, with priority given to those working in work and training history including the scope of mid-the catchment populations of the targeted facilities. wives’ current functions in the community.2. METHODOLOGY The questionnaire then investigated midwives’ knowl-• Target population: All registered village mid edge on danger signs during all stages of pregnancy, wives in Kassala state. and their skills in day-to-day work. The questionnaire• Sample size: 154 midwives also asked about their needs.• Survey sites: Midwives were interviewed before they had undergone training as part of • Administration of questionnaire: 98% were the project activities. self administered, and the remaining was filled in by• Response rate: 100% trained interviewers.• Data collection tool: Questionnaire 13
    • • Quality assurance: pretesting of the question- while the rest worked exclusively in the community.naire was done on a sample of health personnel in 83% of the VMWs stated that they did not receiveAhfad Health Centre. Necessary changes were made a regular salary for their midwifery services. Of theaccordingly. The following points were assessed in midwives that did receive a regular salary, 56% didthe pretest: so from the MoH and 44% from other sources (NGOs and UN agencies). The type of support that they re-• Whether or not the respondents understood ceived the least from the MoH or NGOs was provision questions as intended of midwifery supplies (11%). They especially lacked• How respondents reacted to some questions support in obtaining midwifery supplies, e.g. dispos- perceived as sensitive able materials (gloves, suture materials, etc.), and• Whether questions were in logical order equipment, as well as FP methods. 73% declared that• Whether skip rules for the questions were they replenished their midwifery supplies by buying correct them out of their own pocket, while the others man- aged to get most of their supplies free from the MoH, NGOs and UN agencies. 91% of midwives expressed a3. RESULTS need for more support, specifically in terms of sup- plies (98%), supervision (96%) and salaries (90%).DEMOGRAPHIC CHARACTERISTICS AND WORK EX- 91% of the midwives stated that they have receivedPERIENCE some sort of training during their services, and more63% of VMWs interviewed were between 30 and 50 than 70% of that training was during recent yearsyears old. VMWs below the age of 30 constitute 11% (from 2010 onwards). 99% stated that they providedof all Kassala midwives. Only 3% came from a fam- ANC services to their communities, and 97% statedily of midwives. 72% of the MWs stated that they that they also provided postnatal care. Midwivesworked both in the community and at a health facility, lack enough knowledge on counselling women on FP14
    • methods other than oral pills and injections. Only KNOWLEDGE ON DANGER SIGNS DURING PREG-36% stated that they managed to provide some kind NANCY, LABOUR AND PUERPERIUMof FP services to women who need them, mostly OCP(38%) and to a lesser extent condoms (8%). 84% of The VMWs’ knowledge was high on all major warn- ing signs during all periods of pregnancy and for new-midwives gave FP counselling (benefits, side effects)before they provided the FP method. 66% stated thatborns (97%-100%), but when interviewed on theirthey distributed prenatal vitamins to women dur- knowledge of HIV/AIDS, their knowledge droppeding ANC when it was available to them. They are notsignificantly: 30% did not know that the HIV virus could be transmitted from mother to child duringable to constantly distribute prenatal vitamins sincethey are not supported by the MoH due to their un- pregnancy, labour and birth, and 38% did not knowemployment. They do get a sporadic supply of drugs there are drugs that could prevent mother to childfrom UN or NGOs but this is not sustainable. Only HIV transmission. They showed a clear lack of knowl-59% of midwives said they actually helped women edge on HIV/AIDS issues and on offering counsellingprepare birthing plans. on HIV/AIDS during pregnancy or voluntary testing. The midwives are aware of most danger signs duringConcerning FGM issues, 77% said they did advocate pregnancy and labour but they lack support to verifyagainst FGM and re-infibulations, but 13% admitted these warning signs (e.g. no sphygmomanometer tothey performed it upon request. More than 90% of monitor blood pressure, no kits to monitor proteinsthe midwives provided counselling and advice on in urine), especially if the delivery is a home delivery.breastfeeding, immunization and early child care.Only 39% provided counselling and offered HIV/AIDStesting by referral. 15
    • ANC PRACTICES (SKILLS) low performance in the following: monitoring blood- pressure during delivery (27% did it). Only 11% main-The VMWs were interviewed about the services pro- tained an intravenous line. 89% of midwives statedvided and the skills they practice during antenatal that they performed episiotomy routinely during eachcare (ANC). They reported a high-level performance birth. 87% reported that they registered their deliver-on most skills (history taking, signs and symptoms of ies in a log book. 94% reported that they were ableanaemia, breast examination, foetal heart sounds, to assess and recognize postpartum haemorrhage,lower limb oedema, general prenatal and postnatal but 87% said they referred cases immediately to theadvice) (92% - 98%). Some skills were poorly reported nearest HF. Although the VMWs did not administerby the midwives: 62% did not usually measure blood anti-convulsion drugs, 91% reported knowing how topressure, 30% did not offer prenatal vitamins, 40% place the patient in a safe position during the convul-claimed they did not offer ANC to known HIV positive sions until referral. Concerning newborn care, 66% ofmothers. 86% did order lab tests for mothers in near- midwives performed nasal suction on newborns, 40%by laboratories, and 59% did not register outcomes of offered BCG vaccination to newborns (by counsellingANC visits for each client. and referral), and 40% of midwives did not take mea- surements of newborns.DELIVERY AND POST-DELIVERY PRACTICES (SKILLS) HYGIENE PRACTICESThe questionnaire then explored the midwives’ prac-tices and skills during delivery. The midwives report- The questionnaire then explored the midwives’ hy-ed good practices in the following skills (uterine mas- gienic practices. 82% of community deliveries oc-sage, episiotomy repair, controlled cord traction and curred at women’s homes and 16% at the midwives’monitoring of foetal heart) (92%-99%). They reported homes where a hygienic environment is more under16
    • their control. 92% reported using disposable gloves means of transportation readily available and theyand 16% reported using re-usable gloves. 42% of sometimes have to deal with things on their own.midwives reported using non-sterile suture materialon women after birth and 99% reported using sterile Midwifery cadre qualified as skilled birth atten-objects to cut the umbilical cord. Concerning steril- dants are lacking in Sudanese communities. Fullizing methods, 84% reported using water boiling as midwifery care is actually provided by a number ofa sterilizing method, 16% used alcohol as a sterilizing health cadres in the system. The most qualified cad-method, and 6% used direct heating over a flame as res who provide the full range of midwifery carea sterilizing method. The longest duration reported are largely concentrated in Khartoum state. The Su-for sterilizing instruments was 30 minutes (51%), fol- danese health system recognizes the need to im-lowed by 20 minutes (31%). prove midwifery care both in numbers and quality. Almost all the areas considered to be part of an enabling environment are not present for com-ROLE IN BIRTHING PLANS munity based midwifery services: village mid- wives are not employed in the health system andFinally, the questionnaire explored the midwives’ have no job security, there is poor supervision androle in the preparation of birth plans with expect- monitoring, there is no career pathway and lim-ant mothers. 56% of midwives claimed they assisted ited chances for continued education, there is no/mothers in making birthing plans (mostly just by en- poor access to supplies and medications and poorcouraging women to save money for birth) (79%) and links with referral services. Facility based midwivestransportation arrangements (17%). They do have also face the similar limiting factors. Midwives in ru-decision-making authority to decide when to refer ral Kassala and Kassala city are in dire need of traininga woman to a health facility but they reported that and support especially permanent employment.most families, especially in rural areas, do not have 17
    • CONCLUSION PHC in Kassala is weak. It is even weaker in rural parts of Kassala. PHC in a country plays a major role in enhancingThe Sudanese health system provides a minimum or weakening a community’s sexual and reproductivepackage of PHC that has reproductive health (RH) as health. Universal access to SRH services means equala central component. RH services in a primary care access for everyone with equal needs. To achieve uni-setting should provide the following through a quali- versal access to sexual and reproductive health at thefied and competent health team: level of primary care, equality and rights have to be core components in designing any RH programmes. PHCUs• Assessment of the sexual and reproductive in Kassala show numerous barriers to reach quality SRH: needs of the community: surveys, screening, treatment, referral system. • Run-down facilities and shortages of• Sexual and reproductive health education and equipment counseling. • Limited and inconsistent options for RH ser-• Family planning: all options should be made vices available for communities available with proper non-discriminatory • Shortages of motivated health workers and counseling (benefits and side effects). unwillingness of qualified health workers to• STI (including HIV), RTI work in remote areas.• Reproductive tract cancers • Lack of awareness in the community of the• Post-abortion care full range of services that their PHC should• Quality ANC provide for them.• Skilled care during birth and PP for the mother and the newborn All the above factors coupled with social and traditional barriers make universal access to quality SRH an impos- sible goal.18
    • Recommendations & way forward:• Community baseline assessment (services, • More commitment is needed from the MoH needs, knowledge & attitudes) should be im- to establish Basic EmOc services closer to the plemented before any action plan or budget is rural community (e.g incentives for doctors to put forward for any community based initiate work in rural communities). in RH. • More advocacy is required for task shifting• Intensify community awareness raising on among RH health personnel so as to improve pregnancy danger signs and delivery pre- maternal health in Sudan. paredness.• Intensify VMW awareness raising on select- ed topics and skills training (evidence-based training).• Intensify VMW awareness raising on the im- portance of early referral as well as participa- tory birth planning with mothers.• Establish hospital-based health promotion units that target women after ANC or birth to educate them on danger signs/RH issues. 19