Against All Odds: Maternity Care in Rural North Darfur

Fifteen-year old Sameera [patient’s name changed] had already been in labor for two days when her family decided to leave the valleys and farming plots of Jurajeem to seek the help of a doctor. After a day’s journey, they arrived in Um Baru, a town in the Dar Zaghawa area of Sudan's Darfur region, where Doctors Without Borders/Médecins Sans Frontières (MSF) runs a health center. There, midwife Halom Abdallah discovered that the baby’s head was pressing on the mother’s bladder, putting Sameera at risk of developing a fistula. Yet there was an even bigger risk: according to the World Health Organization (WHO), most maternal deaths occur during or right after delivery.

Fortunately, three hours after she arrived at the MSF health center, Sameera delivered a healthy baby boy.

Sameera and her baby were lucky. In Dar Zaghawa region, countless pregnant women like her seek medical care only when their situation is critical. By then it is often too late. A 2010 Sudan Health Household Survey shows that of every 100,000 babies that are born in North Darfur, 640 mothers die. That is a higher maternal mortality rate than in Sudan's capital, Khartoum, where of every 100,000 births, 389 mothers die. To put those numbers in perspective, consider that of every 100,000 births in Europe, an average of 20 mothers die every year, according to the WHO.

The Risks of Being Pregnant

Pregnancies among adolescent girls carry the highest risk for complications, as the mother’s body has not fully developed. The pelvis has not reached its full size and may cause obstructed labor, putting both mother and baby at risk. Moreover, the needs of the growing fetus put adolescent mothers at a higher risk of anemia and post-partum hemorrhage. Babies may also be born prematurely and underweight. The support of a midwife, medical doctor, or obstetrician during labor, delivery, and in the first hours after birth is essential for both the young mother and the newborn.

Even after birth, babies in Sudan are still at risk: The neonatal mortality rate is 33 deaths per 1,000 live births, compared to an average of about seven deaths per 1,000 live births in many European countries (WHO 2010).

“Women in the area often deliver at home with assistance from traditional birth attendants who do not have the essential training or skills to tend to women with complicated deliveries,” says Halom. “In cases like Sameera’s, where she is a first-time mother, there’s a great chance we may lose the child, mother—or worse, both.”

Sparse Access to Medical Care

The reality is that there are not enough health facilities or birth attendants to serve the women of Dar Zaghawa region, which has a population of more than 20,000. Other than two MSF doctors and one MSF midwife, three Ministry of Health midwives are the only skilled birth attendants able and equipped to manage complications related to labor and delivery. Halom is the only midwife in the Um Baru area. Yet for many women, Um Baru is the closest health facility. It took Sameera an entire day to get here by donkey cart. By car, the journey would have taken just a couple of hours, but few can afford to rent a car even when a baby is on its way.

Together with the Sudanese Ministry of Health, MSF provides a range of free services in maternal health in Dar Zaghawa and Tawila in North Darfur, including antenatal and postnatal care, delivery services and family planning, and sexually transmitted infection treatment and counseling.

“In 2012, we delivered over 900 babies in North Darfur,” says Fernando Medina, MSF head of mission in Sudan. "However, educating women on the importance of a safe delivery in the hospital is another crucial part of the equation. Last year we had over 50 community health workers in MSF-supported health facilities in Dar Zaghawa, Shangil Tobaya, and Tawila, visiting people to discuss the benefits of seeking antenatal and postnatal care, a safe delivery in the hospital, family planning, breastfeeding, and vaccinations. We have seen a five-fold increase in the number of women seeking postnatal care and we have seen over 12,500 women during pregnancy. But we still want to reach more women.”

Saving Lives: Prevention, Skilled Care, and Referrals

Post-partum hemorrhage and infection are the main causes of maternal death. Yet, even in resource-poor settings like Um Baru, it is relatively easy to prevent these deaths if there is access to medication and skilled labor. When pregnant women come to the health centers, health practitioners are able to follow the health situation of the mother and baby, discuss birth options, and prepare mothers for delivery. Antenatal care is critical for determining risks and detecting complications that can impact the mother and baby’s health early on.

In addition to health centers, maternity waiting houses are also gaining acceptance in the region. Here, women from remote areas with at-risk pregnancies can stay near the medical facility a few weeks before their due date to ensure they can get to hospital when labor begins. MSF runs several of these facilities around the world, and opened a 20-bed maternity waiting house in Tawila locality, North Darfur, in 2013.

Even after a healthy delivery, the following few hours are critical. Without skilled care, a quarter of all newborns die in the first 24 hours, reports the WHO. The causes of neonatal death include pro-longed or obstructed labor that leads to fetal distress, premature and low-birth weight, birth trauma, and respiratory distress.

Post-delivery consultations are best continued in the six weeks following the birth. This allows health workers to help with breastfeeding, identify and treat infections, take care of routine vaccinations for the baby, and offer family planning. If a case is too complicated, women are referred to Elfasher Hospital, about 300 kilometers [about 186 miles] away in the capital of North Darfur state. MSF covers all transportation and medical costs for the women and their caretakers.

Since 1979, Sudanese and international MSF staff, together with the Sudanese Ministry of Health, have been providing medical assistance to the people of Sudan suffering from the effects of poor access to health care, natural disasters, nutritional crises, epidemics, and armed conflict. Some of the services offered by MSF include reproductive health care; kala azar treatment; counseling services; and nutritional, pediatric, and emergency obstetric care. MSF runs medical activities in health facilities in Tabarak Allah in Al-Gedaref State, Azaza Damous in Sennar State, and in Tawila, Kaguro, and Dar Zaghawa in North Darfur State.

Sudan 2013 © Asia Kambal/MSF