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Sudan: midwives, home clinics stand in for conflict-shuttered health facilities

One woman in white, head covered covering using a blood-pressure sleeve on another woman whose head is also covered.

Midwife Al Toma Hussein Balal receiving a pregnant woman during a pre-natal visit in Dilling, Sudan. Photo: Momentum Integrated Health Resilience (MIHR)

Midwife Al Toma Hussein Balal receiving a pregnant woman during a pre-natal visit in Dilling, Sudan. Photo: Momentum Integrated Health Resilience (MIHR)

On April 15, 2023, conflict between two armed factions erupted in Sudan, leading to more than 15,000 civilian deaths (according to the UN), along with 6.5 million internally displaced people and 2 million refugees over the last 11 months, adding up to a deepening, ongoing humanitarian crisis. The ongoing armed conflict has had a devastating effect on maternal health.

In the region of South Kordofan health facilities have been looted and closed.  Amira, an expectant mother, can’t travel to open facilities in North Kordofan because the roads are too unsafe.  This is just one crucial reason why midwives like Al Toma Hussein Balal are so important in times of crisis, filling an essential gap for new and expectant mothers like Amira, pregnant with her fifth child but now cut off from health facilities.

Al Toma Balal, a member of the South Kordofan Midwifery Association (SKMA), has turned part of her house into a small clinic in the town of Dilling, where she can check on the health of pregnant women and assist them in delivering safely.

“I am so lucky that I have Mrs. Al Toma Hussein close to me,” Amira says. “I go to her house for my ante-natal visit where she examines me and provides me with some health education. I am sad that the vitamins that I used to take during my previous pregnancies are no longer available as most of the pharmacies are closed and no medical supplies arrive to my hometown.”

A woman in white, wearing mask and with head covered, next to a table of medical instruments and supplies.
Al Toma Balal prepares clean delivery sets at her home in Dilling to help pregnant women deliver safely. Photo: MIHR

Through partner Momentum Integrated Health Resilience, CARE Sudan helps SKMA train midwives like Al Toma Balal. The association itself is relatively new, with the aim to assist midwives to provide high-quality and evidence-based maternal and newborn care; influence reproductive, maternal, newborn, and child health policies; and advocate for and represent all midwives in Sudan’s South Kordofan state.

Between January and April 2023, SKMA conducted on-the-job training and clinical mentoring for 100 facility-based midwives and 43 community health workers on maternal and newborn health care.

Topics included danger signs during pregnancy, complications during pregnancy and delivery, neonatal resuscitation, prevention, and referral criteria for sexual and gender-based violence during pregnancy.

Exterior gate of a hospital building, sign reading
Mother Bakhita Maternity Hospital in Dilling remains closed to everything but emergencies as armed conflict continues in South Kordofan. Photo: MIHR

“I have been working as a trained midwife since 2003,” Al Toma Hussein says. “I was working at Mother Bakhita [Maternity] Hospital, which sadly was closed due to the conflict in South Kordofan.”

“Now I receive pregnant women at home and check on the fetus size and growth using my bare hands as there is no ultrasound available in the town.”

“I help mothers to have safe and clean deliveries at my home and keep them there for four hours to ensure that both mothers and their babies are in good health before letting them go home,” Al Toma Balal says. “Most of the time, I provide my services for free as most of the pregnant woman are very poor and do not have money to pay me.”

Midwives into the gap

Momentum began its partnership with the SKMA in September 2022, to help improve the quality of maternal, newborn, and child health services and to strengthen the association’s capacity to deliver these services.

According to 2022 stats from the World Health Organization, Sudan’s infant mortality rate (deaths per 1,000 births prior to age 1) is 38.95, while only 51 percent of mothers receive adequate care during pregnancy (defined as at least four visits from any health provider during the term.)

As of 2020 the maternal mortality rate was 270.4 deaths per 100,000 live births, a number representing 4,122 maternal deaths. This number has almost certainly risen as armed conflict has erupted and health facilities have closed. Neighboring South Sudan had the world’s worst 2020 maternal mortality rate, at 1,222.5 per 100,000, with fellow neighbor Chad close behind at 1,063.5. By contrast, across Europe the average 2020 rate was 13.2.

Exterior image of modest home, constructed of brown stones, on a clear day with blue sky.
Al Toma Hussein Balal’s home is operating as a health facility of sorts, since the midwife turned part of it into a clinic where she assists pregnant women. Photo: MIHR

Momentum’s work began with by training two SKMA midwives, Batol Soulman and Mawhib Abdalnabi Malik. Mawhib also works on behalf of the government health ministry, as a maternal health specialist. This partnership has helped spread knowledge among local partners, helping both mothers and children.

Today SKMA supports midwives in three different towns: Kadugli, Dilling, and Habila. Along with training and mentoring, the SKMA/Momentum partnership helps address ongoing challenges with work environments and supply shortages.

“With the ongoing conflict in Sudan, some 70 percent of the health facilities in the conflict-affected areas are not providing the adequate health care that pregnant and lactating women urgently need besides the significant shortage of medical supplies in these areas,” said Hussein Araban, CARE Sudan Deputy Country Director. “Qualified and trained midwives are the frontliners to fill the unprecedented gap in maternity and reproductive health.”

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