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Effective Strategies To Improve Maternal Health Among Refugee Women In Eastern Sudan (古田 真里枝氏)
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Effective Strategies To Improve Maternal Health Among Refugee Women In Eastern Sudan (古田 真里枝氏)


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  • 1. IDDP 講演 古田 真里枝
  • 2. 国際社会の問題  世界の人々の5人に1人は1日1ドル未満で生活  1000万人の5歳未満の乳幼児が防ぐことが可 能であった病気で死亡  50万人を超える女性が、妊娠・出産により死亡  1億1,300万人の児童が小学校に通っていない
  • 3. MDGs 1. 極度の貧困と飢餓の撲滅 2. 初等教育の完全普及 3. ジェンダーの平等、女性のエンパワーメント 4. 子供の死亡率削減 5. 妊産婦の健康改善 6. HIV/エイズ、マラリアなどの疾病の蔓延防止 7. 持続可能な環境づくり 8. グローバルな開発パートナーシップの構築
  • 4. Where is the “M” in MCH? (Rosenfield & Maine 1985)
  • 5. “Maternal mortality is a neglected tragedy, neglected because those who suffer it are neglected people with the least power and influence over national resources shall be spent; they are the poor, the rural peasants, and above all women” (Mahler 1987)
  • 6. Introduction Maternal Mortality Ratio (1995) (per 100,000 live births) VERY HIGH - 600 or more MODERATE - 300-599 LOW – 100-299 LOW - less than 100 No data Source: WHO,UNICEF, UNFPA, Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA. Geneva, 2001
  • 7. UNFPA/UNHCR Reproductive Health Services Joint Project In full compliance with the ICPD spirit, and following the Memorandum of Understanding signed between UNFPA and UNHCR earlier last April, a new joint project had been signed for the provision of Reproductive Health services in the Refugee Camps of Kilo 26, Um Gargur, Wad Sherifey, Shagarab 1,2,3, Girba, Wad Hilleaw, Abuda, and Suki where 107,000 Refugees live in Eastern states of Kas-sala and Gedaref. Although many Eritrean refugees have gone back to their country, estimations show that still approximately 300,000 refugees remain in the Sudan of which 110,000 are camp-based, mainly in the two states of Kassala and Gedaref. The situation of forced migration for a prolonged period of time and short- term planning as dictated by refugee status, has a profound negative impact on the quality of life. Due to donor fatigue, resources for the delivery of services to the camp based refugees has been declining, over the years, leading to inadequate provision of social services including their education and health care, which has contributed to their low health status in general. For new arrivals who are at their early stage of reproductive age, they endure physical hardship and fatigue as well as psychological trauma during the process of displacement. Women refugees, however, face additional stresses. In addition to the high prevalence of early, un-timely and poorly outcome of pregnancies and childbirths, the very high risk for STDs/HIV/ AIDS is coupled by the potentiality of Gender-Based Violence (GBV), which may be pressured to exchange sexual favors for food and thus increase the exposure to the risk of infectious disease including sexual transmitted infections (STI) in refugees.
  • 8. Objective  To explore and develop effective strategies to improve maternal health among refugee women in Eastern Sudan
  • 9. Methods  Situation Analysis  In-depth interviews - reproductive-aged women  Informal discussion - health workers, key informants  Analytical & Planning tool  PRECEDE-PROCEED MODEL
  • 10. PHASE V PRECEDE-PROCEED Model PHASE IV PHASE III PHASE II PHASE I ADMINISTRATIV EDUCATIONAL BEHABIORAL AND EPIDEMIOLOGICAL SOCIAL E AND POLICY AND PROCESS ENVIRONMENTAL DIAGNOSIS DIAGNOSIS DIAGNOSIS DIAGNOSIS DIAGNOSIS PREDISPONSING FACTORS HEALTH BEHAVIOR AND PROMOTION HEALTH ? LIFESTYLE Low utilization of EDUCATION - Family planning COMPONENTS - Skilled delivery QOL Care. - EmOC Maternal Practice of FGM death affects HEALTH the children’s •REINFORCING FACTORS High ratio of family’s and ENVIRONMENT maternal mortality community’s POLICY & morbidity ? life REGULATION •Population 7,282 ORGANIZATION •1 health centre High prevalence of anaemia & Some Not covered by •Nearest facility infectious disease morbidity Sudan national with Com. EmOC is (Malaria) MCH Program cause 50km away depression, “1 Village Midwife ENABLING FACTORS •Road condition is stigmatization for 2,000 bad One primary population” etc. . school one for each . . boy & girl ? •No electricity •Homogeneous community Adopted from LW. Green and M.W.Kreuter,
  • 11. Sample Characteristics of Interviews No. Ag # of living Education Work Education Work Children (wife) (wife) (husband) (husband) e 1 28 6 None No Primary Farmer 2 28 4 None No Primary Baker 3 30 6 Primary No None Farmer 4 35 6 Primary No None Driver (Come back home twice/m) 5 27 6 Primary No Secondary Vegetable 6 28 6 Primary No Religious Seller Vegetable 7 34 6 Primary No Sc Secondary Seller Farmer, 8 26 3 Primary No Secondary Teacher Farmer 9 30 8 None No Primary Farmer (polygamous union) 10 20 3 None No
  • 12. Why do women receive FGM? Who is conducting FGM? “My mother and mother-in-law decided on sunna for my daughter. We asked a midwife to perform it, but she refused. She is new here, having come from another camp, and she said that sunna is not good for health. So my mother- in-law did it. Although she had never done it before, she knew how from her experience. Women who don’t receive this practice cannot marry because it creates a sense of identity and belonging in our society.”
  • 13. Result 1: What is preventing women from receiving FP services?  Belief that controlling fertility using contraception is against God’s will  Desire to have more children  Gendered position requiring women to follow their husband’s wishes and thus no power to influence the decision-making process  Worries about side-effects of contraception
  • 14. What is preventing women from receiving FP services? (cont.) “If I am healthy and if God likes, I want to have more children, but now I want spacing because I have just delivered a baby. But, I have never discussed FP with my husband because I know he doesn't want spacing. I don’t do anything that my husband doesn’t want.” (28-year old woman with 6 children) “ I took pills (before), but I became sick because of the side effects, so we changed to condoms. But after my husband started to use condoms, I got vaginal infections, so we stopped. Then I became pregnant.” (35-year old woman with 6 children)
  • 15. What is preventing women from receiving skilled delivery care?  Limited number of skilled birth attendants (Village Midwives: VMWs) who are not always available  Poor quality of delivery kits that midwives use
  • 16. Result 3: What is preventing women from receiving EmOC? Delay in decision to seek EmOC  Lack of women’s decision-making ability  Lack of preparedness of family members for emergencies, and  High cost of drugs and medical supplies
  • 17. What is preventing women from receiving EmOC? (Cont.) “My mother died during labour while delivering the next baby after me” “Deaths related to labor are difficult to prevent, even by midwives. Death or survival is up to God.” “I cannot decide to go to a health centre without asking my husband”.
  • 18. Why do women delay to receive EmOC? (cont.) Delay in arrival at the point of care  Referral sites are far away, and travel becomes very difficult during the rainy season over poor roads.  Lack of means of transportation such as ambulances with obstetric first aid equipment.
  • 19. Why do women delay to receive EmOC? (cont.) “My anti died during labor last year because of severe breeding. She was delivering at home with a midwife. It was difficult to move her because it happened suddenly and we could not find transportation. So she died at home”.
  • 20. Why do women delay to receive EmOC? (cont.) Delay in provision of adequate care  Lack of medical staff who can provide EmOC.  Lack of medical equipment for EmOC.
  • 21. “We have only basic delivery equipment here. We cannot provide blood transfusions. The equipment is just a little better than what midwives use for home delivery ” “Problems often happen during the night…. If we bring a patient to the health centre at night, we have to treat her in darkness. We don’t have any lights… it is difficult to see how much a woman is bleeding.” (MWs)
  • 22. PHASE V PRECEDE-PROCEED Model PHASE IV PHASE III PHASE II PHASE I ADMINISTRATIV EDUCATIONAL BEHABIORAL AND EPIDEMIOLOGICAL SOCIAL E AND POLICY AND PROCESS ENVIRONMENTAL DIAGNOSIS DIAGNOSIS DIAGNOSIS DIAGNOSIS DIAGNOSIS PREDISPONSING FACTORS The capacity of    •Controlling fertility is against God •Contraception has side effects do nothealth staff to     HEALTH •Pregnancy & childbirth are natural process that BEHAVIOR AND PROMOTION require special attention LIFESTYLE •Maternal deaths are not avoidable HEALTH •FGM deliverof belonging to the society create sense effective    Low utilization of EDUCATION •Knowledge of child-spacing methods is low - Family planning QOL COMPONENTS health education for •Women reluctant to seek healthcare without - Skilled delivery Care. permission from husband or mother-in-law - EmOC local people •Men reluctant to marry women without FGM Practice of FGM Maternal death affects HEALTH the children’s •REINFORCING FACTORS High ratio of family’s and POLICY A supportive •VMW refuse to practice FGM •Elder teach young people that girl should be ENVIRONMENT maternal mortality & morbidity community’s life REGULATION ORGANIZATION environment for married in the middle of teenage. •Polygamy is widely acceptable •Population 7,282 •1 health centre High prevalence of •Men want children as many as possible anaemia & Some Not covered by Sudan national Safe Motherhood •Voices of women are devalued. •Nearest facility with Com. EmOC is infectious disease (Malaria) morbidity MCH Program cause 50km away depression, “1 Village Midwife ENABLING FACTORS •Road condition is for 2,000 population” The capacities of HC to •Iron/folic are freely available for pregnant women •Women have good relationship with VMW bad One primary stigmatization etc. . school one for each . deliver effective •MAs and VMWs are 24 hours on call •Bicycles are available for outreach services boy & girl . •No electricity outreach services •Some children are attending primary school •Some people have donkeys and a few have camel •Homogeneous More than half of women are illiterate community •Cannot afford drugs even if it available •Shortage of health workers with life saving skills, A local capacity for and family planning counselling skills •Lack of satisfaction of MA with their working accessibility of EmOC condition •Lack of medical equipments, drugs in HC •No ambulance or cars with first aid and for effective referral •Lack of means of communication system Adopted from LW. Green and M.W.Kreuter,
  • 23. Project (SHARES) Matrix Goal To improve QOL of refugees by contributing to the sustainable improvement of Maternal Health Purpose To strengthen the capacity of health centres to promote maternal health, and to deliver quality maternal health services Outputs Education Training course Strengthened Effective and activities carried delivered to enhance capacity of health accessible referral on in communities to provision of centres to deliver system and to promote effective health effective outreach information for all supportive social education for the services for women pregnant women norms and community to adopt during pregnancy, and their families environment for healthy behaviour childbirth, and the a SM related to SM postpartum period a Activities •Clarify who the •Establish HET •Provide VMW •Set up DRF in HC influential people •Conduct workshop training •Develop logistics •Create HPC of HET on PLA •Provide delivery system for drugs •Facilitate HPC to •Support HET to kits •Develop referral link with others to facilitate PNA. •Provide CHV system for integrate their •Integrate HET training on emergencies activities activities with others maternal health •Develop •Use child-to-child •Provide refresher community action approach courses for health group to lobby for a a staff better referrals a
  • 24. Conclusion Capacity building in health education and health services ensuring involvement of local people and staff was considered critical in improving maternal health in the refugee setting. A planned community-based project reflecting this and implications for other healthcare settings will also be considered.
  • 25. Thank You!