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 CONTENTS

Introduction Project objectives

Baseline survey on KAP of women in communities of the two targeted localitiesObjectivesMethodology

ResultsGeneral demographic characteristics of sampled womenANC ExperienceFamily planning experienceKnowledge on danger signs during pregnancyKnowledge on danger signs during laborKnowledge on danger signs during puerperiumKnowledge on danger signs for newbornsKnowledge on HIV/AIDSBirth experience and birthing plans

Baseline survey on KAP of all VMWS in Kassala stateObjectivesMethodology

ResultsDemographic characteristics and work experienceKnowledge on danger signs during pregnancy, labour and puerperiumANC practices (skills)Delivery and post-delivery practices (skills)Hygiene practicesRole in birthing plans

Conclusion

Recommendations & way forward

4 4

5

55

77789

1010101111

131313

141415

16161617

18

19

INTRODUCTION

Project objectives:The overall goal of the project is to contribute to im-proving the health and wellbeing of mothers, new-borns and their families in two localities in Kassala state, Kassala town and rural Kassala.

Specific objectives of the project include the follow-ing:1. Improving the quality and uptake of maternal and neonatal health care in 19 health facilities and surrounding communities. This will be accomplished through:a) Development of an assessment framework for a rapid baseline assessment of existing local Pri-mary Health Care Units (PHCUs). b) Building the capacity of the PHCUs, i.e. im-proving the competency of relevant health cadres through a series of in-service trainings and refurbish-ing and equipping health facilities.c) Sensitizing and organizing the communities to take an active part and support the sustainability of the project interventions.

d) Developing a generalizable and replicable model that enhances reproductive health (RH) ser-vices to address MDG 5 and MDG 4 through thorough documentation and monitoring of the implementa-tion process, use of evidence-based interventions and taking into account lessons learned.

2. Contributing to ensuring that all pregnant wom-en and their newborns in the two localities are cared for by a trained health worker during pregnancy and childbirth. This will be done through provision of im-proved health care at community and primary health care levels, backed up by a functioning referral sys-tem.

To assess the community baseline status, two surveys were conducted; a KAP survey among community women and a KAP survey among all registered VMWs in Kassala state.

4

1. OBJECTIVESTo assess the knowledge, attitudes and practice (KAP) of women in the community regarding various RH is-sues (use and knowledge of FP methods, pregnancy danger signs, opinion on home delivery versus facil-ity delivery, birthing plans, HIV/AIDS and opinions on midwives’ capabilities). The target women were mothers with a delivery event not more than 5 years ago.

2. METHODOLOGY• Study population: Women of reproductive age in the two localities who had a pregnancy experience during the past 5 years.• Sample size: 800 women, 500 from rural Kassala and 300 from Kassala town. • Sampling methodology: Both localities, although classified as urban and rural, are considered similar (in terms of demographic and household characteris-tic features) and the comparison was within the state, not between states (i.e. no clustering features).

BASELINE SURVEY ON KAP OF WOMEN IN COMMUNITIES OF THE TWO TARGETED LOCALITIES

Therefore, both localities acted as one target popu-lation, but differences in the average size of house-holds between the localities had to be considered in the sampling procedure.

The two localities are significantly different in terms of the number of households, so the total sample was divided between the two localities proportionally to size (PPS).

• Sampling within each locality was multi-stage sam-pling:1. From the catchment villages, the 10 most popu-lated villages in each locality were chosen, and from these, 5 villages were chosen randomly (primary sampling units).2. Since the 10 villages in each locality are not equal in size, the 5 chosen villages were selected using PPS. To do that, the cumulative frequency of number of households of the 10 villages in each locality was cal-culated. Then, random numbers using the number

5

of digits equivalent to the total number of households to be sampled were obtained from tables of random numbers (not computerized tables). The villages con-taining the random numbers were the villages from which samples were taken.

3. Then, an equal number of households with 1 wom-an/household (secondary or main sampling units) were selected from the chosen villages by simple random sampling (SRS) (or using methods the ground team found more feasible).

• Response rate: 90%.

• Data collection tool: A questionnaire was de-veloped by the AUW team to be filled in by trained interviewers. Interviewers were recruited and trained to interview the target women. A pretest was per-formed on a sample of 100 households. Data collec-tion commenced on 23rd Dec 2011 and concluded on 7th Jan 2012. • Questionnaire design: The questionnaire was written in Arabic. The questionnaire was long but sim-ple, and could be administered by the respondents

themselves or via interview. The questions are spread over five sections. Options included both open and closed questions. Responses to the questions did not contain long recall periods but concentrated mostly on current practices. The questions were easy, non-threatening and not sensitive. They started off with simple demographic questions about the sampled women. Then the questionnaire explored the RH ser-vices the women received during their pregnancies (ANC, birth, abortion care and FP). Then their knowl-edge of various RH topics was explored (FP, danger signs, birth planning).

• Quality assurance: Interviewers were chosen according to significant past experience of conduct-ing interviews. 10 interviewers were chosen and re-ceived one week’s training before the survey. Pretest-ing of the questionnaire was done on a sample of 50 households and necessary changes were made ac-cordingly. The following points were assessed in the pretest:

• Whether or not the respondents understood the questions as intended

6

• How respondents reacted to some questions perceived as sensitive• Whether questions were in logical order• Whether skip rules for the questions were correct• The length of the questionnaire

2. RESULTS

GENERAL DEMOGRAPHIC CHARACTERISTICS OF SAMPLED WOMENThe questionnaire started with basic demographic questions. The sample women consisted of women of reproductive age who have given birth at least 5 years ago. Almost 30% of the sample were young mothers (less than 25 years old) and almost 70% of the sample women had a very low level of education (illiterate or primary level education). Almost 60 % had a child less than 3 years ago, 15 % were pregnant at the time of the survey and 25 had a child less than 5 years ago. Therefore, the survey reflected recent rather than old experiences. Nationally, 90% of households in Sudan

have at least one female of reproductive age (SHHS 2012). 60% of them have had at least one birth, and 35% of them are not educated. This reflects the importance of safe motherhood and RH issues in a country like Sudan. Kassala has one of the worst RH and childhood indicators.

ANC EXPERIENCE

The first section of the questionnaire examined the ANC experience of the sample women and the type and quality of care they received during their last pregnancy. Almost 44% of the women said they had ANC during their last pregnancy in a health facility (HF) only, while 21% had ANC both in a HF and from a midwife. Just 5% stated they had ANC from a VMW only, mainly because it was a family tradition (98%). Regarding frequency of visits, 66.6 % of women stated that they went to ANC every month during their last pregnancy. A small percentage stated they received no ANC during their last pregnancy (2.4%), while 4.4% had one ANC visit. 17% said they had one visit every trimester and 10% had one visit at the beginning of

7

pregnancy and one towards the end of pregnancy. The subsequent questions assessed the quality of the visits they received. More than 94% of the women stated that they had received good care, in terms of checking their history of previous pregnancies and deliveries, measuring blood pressure, and abdominalexaminations. 42% did not have an eye examination for anaemia or chest examination, 90.4% did not receive a breast examination, and 89.9% did not re-ceive advice or info on HIV/AIDS prevention and test-ing. 61% did not have their lower limbs examined for oedema. 89% stated that their caregiver did request laboratory tests for urine and Haemoglobin.

Antenatal care’s effect on maternal mortality has been under great debate. More and more systematic reviews of ANC in developing countries illustrate that a greater frequency of ANC visits does not necessarily reduce maternal mortality. They highlight the effect of the quality of the visits as more significant. ANC should be a means to detect women at a higher risk of developing complications during pregnancy and/or birth. Maternal mortality in developing countries has been shown to be more obstetrical-related and

occurring during birth rather than during pregnancy. Post partum mortality also contributes significantly to MM in developing countries. According to this sur-vey, women in Kassala state did have regular ANC vis-its as recommended but it is clear the quality of the visits was substandard. They received services dur-ing the visits that clearly are not designed to identify women who are at risk. Women, especially seen by VMWs in the community, did not regularly have their blood and urine monitored. Also, the VMW survey and training executed during this project highlighted deficits in skills for BP measuring and anaemia detec-tion. ANC seems to be just a routine procedure and has failed to accomplish its purpose as a mechanism of early detection, counselling and advice.

FAMILY PLANNING EXPERIENCE

The second section of the questionnaire explored the experience and knowledge of women regarding dif-ferent types of family planning methods. The types of FP most used by the women were oral contracep-tive pills (CoP & PoP) (48%).

8

In terms of knowledge, oral contraceptive pills were the best known FP method among women (62%) fol-lowed by breastfeeding (LAM) (56%). 82% of women did not know about condoms as a FP method, 49% did not know about hormonal injection and 74% did not know about “safe period” as a contraceptive method. These results go hand in hand with SHHS 2012 that showed Kassala as one of the states where FP was least used (95.6 % of women were not using FP at the time of the survey).

Based on the facility survey, the limited knowledge and access women have to various types of family planning was not surprising. The FP methods most widely available in the targeted PHCUs were oral contraceptive pills. These centres periodically lacksupplies due to inefficient supply chain management. When these commodities are available, they are pro-vided at a charge. Women have to purchase FP prod-ucts from their own pocket.

Currently, according to the latest RHCS assessment 2007, UNFPA satisfies 12% of the country’s demand for family planning. MOH needs to provide the re-

maining demand for FP and to strengthen supply chain management and logistics in its health systems.

We also need to create demand by awareness-raising in the community with an emphasis on the benefits of family planning, and we need to increase access to FP commodities at the community level.

KNOWLEDGE ON DANGER SIGNS DURING PREG-NANCY

The third section of the questionnaire explored the knowledge of the surveyed women regarding dangersigns during pregnancy, labour and newborns. The best-known danger sign during pregnancy was vagi-nal bleeding (92.5%), followed by decreased or no foetal movement (79%), dizziness and/or loss of con-sciousness (74%), and convulsions (74%). Sudden generalized oedema was recognized as a danger sign by 72% of the women. Knowledge of important signs of pre-eclampsia was low; 67% did not know that se-vere headaches are a danger sign, 64.3% did not know that severe vomiting is a danger sign, and 53.3% did

9

not know that blurring of vision is a danger sign. 62% of women did not know that “burning micturition” or fluids escaping from the vagina are danger signs dur-ing pregnancy.

KNOWLEDGE ON DANGER SIGNS DURING LABOR

Exploring the women’s knowledge of danger signs during labour revealed that the best-known dangersign during labour was severe vaginal bleeding af-ter placental removal (82%), followed by delay in placental removal by more than half an hour (75%). Knowledge of risks for precipitating vaginal fistulawas low; 57% did not know that being in labour for more than 12 hours is a danger sign, while 48% did not know that pushing out the baby for more than 3 hours is a danger sign. 54% did not know that sudden loss of the feeling of bearing down during labour (a sign for ruptured uterus) is a danger sign.

KNOWLEDGE ON DANGER SIGNS DURING PUERPE-RIUM

The best-known danger signs during puerperium were severe vaginal bleeding (84%), convulsion (79%), difficulty in breathing (66%) and fever (64%). The least known signs were signs of puerperal sep-sis: foul-smelling lochia (68.2%), and pus from episi-otomy (65.6). Knowledge of signs of pre-eclampsia during puerperium was also low: 70.5% did not know nausea and vomiting, and 63% did not know severe headaches. Knowledge of signs and symptoms of fistula formation was low, as 56% did not know that urine/stool incontinence is a sign.

KNOWLEDGE ON DANGER SIGNS FOR NEWBORNS

The best-known danger signs for newborns were 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% didnot know that blue lips/nails are a danger sign

10

that warrants prompt referral to a health facility. Also, 60% did not recognize that lower conscious-ness or stuperosis in a newborn is a danger sign. Women in Kassala showed very modest knowledge on various danger signs they may encounter dur-ing after their pregnancies. They are receiving mini-mal information from health care providers, in this case mostly VMWs or PHC in general. It is clear that the role of PHC in providing education and dis-seminating knowledge is not met in these localities.

KNOWLEDGE ON HIV/AIDS

93% of the women had heard about HIV/AIDS. 22% did not know that the virus could be transmitted from an infected mother to her unborn child. 40.7% did not know it could be transmitted to the unborn child during vaginal delivery, and 53.4% did not know it could be transmitted via breastfeeding. 83% did not know that there are drugs that prevent motherto child transmission of the virus. 43% did notknow that pregnant women should undergo rou-tine VCT for HIV, and 20% did not approve of this

routine testing. These results are worse compared to the findings of SHHS 2010 about knowledge on mother to child HIV transmission. SHHS 2010 also revealed that only 2% of women in Kassala state have been tested, and only 0.6% of these have ac-tually received their results. This indicates the press-ing need to target these localities with interventions to spread knowledge and provide VCT services.

BIRTH EXPERIENCE AND BIRTHING PLANS

The questionnaire explored the women’s latest birth experience and the existence of a birthing plan if they were currently pregnant. Almost 66% had home de-liveries in their last pregnancy and 70 % of them gave the reasons as being because they themselves insist-ed to deliver at home. For women who did deliver in a health facility, the topic on which they received the most advice after delivery was on breastfeeding (83%). The topic on which they received the least advice was on was FP (83% did not receive advice on FP), cleaningepisiotomy (66%) and on danger signs during pu-erperium (65%). 41% of women who were preg-

11

nant at the time of the survey did not have a birth-ing plan. 80% of those that claimed they did have a birthing plan only did so by preparing emergency funds. Midwives had inputs in only 30% of those birthing plans. For any future pregnancy, 60 % of women still insisted that they preferred home de-livery. 86% of the women thought that their VMWs were capable of handling pregnancy complications.

Women in the two localities had a high rate of home de-liveries, with a strong conviction in their value among the mothers themselves, who insisted on doing the same in the future. This, coupled with the absence of birthing plans prepared by the women, is an alarming fact. Women are insisting on delivering at home with low access to qualified health personnel and a lackof access to nearby EMOC facilities. Interventions tar-geted at social and cultural beliefs should be initiated to encourage to the use of health facilities for birth.

Women in rural and urban Kassala still believe that their VMW is capable of handling any emergency that could happen to them during pregnancy or la- bour, and the women still have a preference for home

deliveries. Programmes should concentrate more on altering this mentality. Women still need to be en-couraged to have a birthing plan, especially in terms of putting aside funds for emergencies during labour or pregnancy. Women still feel satisfied with the ser-vices of midwives. The best-known types of FP among women were injections and combined pills. Women did not know the various danger signs related to ec-lampsia. Knowledge about danger signs during labour was low compared to danger signs during puerperi-um. The women showed the most knowledge regard-ing danger signs in a newborn. Knowledge on HIV/AIDS was alarmingly poor. They wanted to use FP, but they could not have access to methods through mid-wives and had to travel to the nearest HF to get them.

Programmes should focus on changing the mental-ity of women towards facility birth. We believe that if VMWs were officially employed by nearby health facilities, women could be gradually persuaded to deliver in facilities. More support for VMWs in terms of FP methods and education on informa-tion related to HIV/AIDS and training on knowl-edge transfer to women during ANC is also needed.

12

1. OBJECTIVESGeneral objective: To assess the knowledge, atti-tudes and practices of VMWs in the community on various RH issues (knowledge and distribution of FP methods, pregnancy danger signs, delivery emer-gency procedures and referral mechanisms, opinion on home delivery versus facility delivery, birthing plans, HIV/AIDS and pregnancy, training and support requirements, decision-making capabilities). The tar-get midwives were all working in rural Kassala and Kassala town, with priority given to those working inthe catchment populations of the targeted facilities.

2. METHODOLOGY• Target population: All registered village mid wives in Kassala state. • Sample size: 154 midwives• Survey sites: Midwives were interviewed before they had undergone training as part of the project activities.• Response rate: 100%• Data collection tool: Questionnaire

• Questionnaire design: The questionnaire was written in Arabic. The questionnaire was long but sim-ple, and could be administered by the respondents themselves or via interview. The question was distrib-uted into five sections. Options included both open and closed questions. Responses to the questions did not contain long recall periods but concentrated on mostly on current practices. The questions were easy, non-threatening and not sensitive. They started off with simple demographic questions, then moved to work and training history including the scope of mid-wives’ current functions in the community.

The questionnaire then investigated midwives’ knowl-edge on danger signs during all stages of pregnancy, and their skills in day-to-day work. The questionnaire also asked about their needs.

• Administration of questionnaire: 98% were self administered, and the remaining was filled in by trained interviewers.

13

BASELINE SURVEY ON KAP OF ALL VMWS IN KASSALA STATE

• Quality assurance: pretesting of the question-naire was done on a sample of health personnel in Ahfad Health Centre. Necessary changes were made accordingly. The following points were assessed in the pretest:

• Whether or not the respondents understood questions as intended• How respondents reacted to some questions perceived as sensitive• Whether questions were in logical order• Whether skip rules for the questions were correct

3. RESULTS

DEMOGRAPHIC CHARACTERISTICS AND WORK EX-PERIENCE63% of VMWs interviewed were between 30 and 50 years old. VMWs below the age of 30 constitute 11% of all Kassala midwives. Only 3% came from a fam-ily of midwives. 72% of the MWs stated that they worked both in the community and at a health facility,

while the rest worked exclusively in the community. 83% of the VMWs stated that they did not receive a regular salary for their midwifery services. Of the midwives that did receive a regular salary, 56% did so from the MoH and 44% from other sources (NGOs and UN agencies). The type of support that they re-ceived the least from the MoH or NGOs was provision of midwifery supplies (11%). They especially lacked support in obtaining midwifery supplies, e.g. dispos-able materials (gloves, suture materials, etc.), and equipment, as well as FP methods. 73% declared that they replenished their midwifery supplies by buying 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 a need for more support, specifically in terms of sup-plies (98%), supervision (96%) and salaries (90%). 91% of the midwives stated that they have received some sort of training during their services, and more than 70% of that training was during recent years (from 2010 onwards). 99% stated that they provided ANC services to their communities, and 97% stated that they also provided postnatal care. Midwives lack enough knowledge on counselling women on FP

14

methods other than oral pills and injections. Only 36% stated that they managed to provide some kind of FP services to women who need them, mostly OCP (38%) and to a lesser extent condoms (8%). 84% of midwives gave FP counselling (benefits, side effects) before they provided the FP method. 66% stated that they distributed prenatal vitamins to women dur-ing ANC when it was available to them. They are not able to constantly distribute prenatal vitamins since they are not supported by the MoH due to their un-employment. They do get a sporadic supply of drugs from UN or NGOs but this is not sustainable. Only 59% of midwives said they actually helped women prepare birthing plans.

Concerning FGM issues, 77% said they did advocate against FGM and re-infibulations, but 13% admitted they performed it upon request. More than 90% of the midwives provided counselling and advice on breastfeeding, immunization and early child care. Only 39% provided counselling and offered HIV/AIDS testing by referral.

KNOWLEDGE ON DANGER SIGNS DURING PREG-NANCY, LABOUR AND PUERPERIUM

The VMWs’ knowledge was high on all major warn-ing signs during all periods of pregnancy and for new-borns (97%-100%), but when interviewed on their knowledge of HIV/AIDS, their knowledge dropped significantly: 30% did not know that the HIV virus could be transmitted from mother to child during pregnancy, labour and birth, and 38% did not know there are drugs that could prevent mother to child HIV transmission. They showed a clear lack of knowl-edge on HIV/AIDS issues and on offering counselling on HIV/AIDS during pregnancy or voluntary testing. The midwives are aware of most danger signs during pregnancy and labour but they lack support to verify these warning signs (e.g. no sphygmomanometer to monitor blood pressure, no kits to monitor proteins in urine), especially if the delivery is a home delivery.

15

ANC PRACTICES (SKILLS)

The VMWs were interviewed about the services pro-vided and the skills they practice during antenatal care (ANC). They reported a high-level performance on most skills (history taking, signs and symptoms of anaemia, breast examination, foetal heart sounds, lower limb oedema, general prenatal and postnatal advice) (92% - 98%). Some skills were poorly reported by the midwives: 62% did not usually measure blood pressure, 30% did not offer prenatal vitamins, 40% claimed they did not offer ANC to known HIV positive mothers. 86% did order lab tests for mothers in near-by laboratories, and 59% did not register outcomes of ANC visits for each client.

DELIVERY AND POST-DELIVERY PRACTICES (SKILLS)

The questionnaire then explored the midwives’ prac-tices and skills during delivery. The midwives report-ed good practices in the following skills (uterine mas-sage, episiotomy repair, controlled cord traction and monitoring of foetal heart) (92%-99%). They reported

low performance in the following: monitoring blood-pressure during delivery (27% did it). Only 11% main-tained an intravenous line. 89% of midwives stated that they performed episiotomy routinely during each birth. 87% reported that they registered their deliver-ies in a log book. 94% reported that they were able to assess and recognize postpartum haemorrhage, but 87% said they referred cases immediately to the nearest HF. Although the VMWs did not administer anti-convulsion drugs, 91% reported knowing how to place the patient in a safe position during the convul-sions until referral. Concerning newborn care, 66% of midwives performed nasal suction on newborns, 40% offered BCG vaccination to newborns (by counselling and referral), and 40% of midwives did not take mea-surements of newborns.

HYGIENE PRACTICES

The questionnaire then explored the midwives’ hy-gienic practices. 82% of community deliveries oc-curred at women’s homes and 16% at the midwives’ homes where a hygienic environment is more under

16

their control. 92% reported using disposable gloves and 16% reported using re-usable gloves. 42% of midwives reported using non-sterile suture material on women after birth and 99% reported using sterile objects to cut the umbilical cord. Concerning steril-izing methods, 84% reported using water boiling as a sterilizing method, 16% used alcohol as a sterilizing method, and 6% used direct heating over a flame as a sterilizing method. The longest duration reported for sterilizing instruments was 30 minutes (51%), fol-lowed by 20 minutes (31%).

ROLE IN BIRTHING PLANS

Finally, the questionnaire explored the midwives’ role in the preparation of birth plans with expect-ant mothers. 56% of midwives claimed they assistedmothers in making birthing plans (mostly just by en-couraging women to save money for birth) (79%) and transportation arrangements (17%). They do have decision-making authority to decide when to refer a woman to a health facility but they reported that most families, especially in rural areas, do not have

means of transportation readily available and they sometimes have to deal with things on their own.

Midwifery cadre qualified as skilled birth atten-dants are lacking in Sudanese communities. Full midwifery care is actually provided by a number of health cadres in the system. The most qualified cad-res who provide the full range of midwifery care are largely concentrated in Khartoum state. The Su-danese health system recognizes the need to im-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-munity based midwifery services: village mid-wives are not employed in the health system and have no job security, there is poor supervision and monitoring, there is no career pathway and lim-ited chances for continued education, there is no/poor access to supplies and medications and poorlinks with referral services. Facility based midwives also face the similar limiting factors. Midwives in ru-ral Kassala and Kassala city are in dire need of training and support especially permanent employment.

17

CONCLUSION

The Sudanese health system provides a minimum package of PHC that has reproductive health (RH) as a central component. RH services in a primary care setting should provide the following through a quali-fied and competent health team:

• Assessment of the sexual and reproductive needs of the community: surveys, screening, treatment, referral system.• Sexual and reproductive health education and counseling.• Family planning: all options should be made available with proper non-discriminatory counseling (benefits and side effects). • STI (including HIV), RTI• Reproductive tract cancers• Post-abortion care• Quality ANC• Skilled care during birth and PP for the mother and the newborn

PHC in Kassala is weak. It is even weaker in rural parts of Kassala. PHC in a country plays a major role in enhancing or weakening a community’s sexual and reproductive health. Universal access to SRH services means equal access for everyone with equal needs. To achieve uni-versal access to sexual and reproductive health at the level of primary care, equality and rights have to be core components in designing any RH programmes. PHCUs in Kassala show numerous barriers to reach quality SRH:

• Run-down facilities and shortages of equipment• Limited and inconsistent options for RH ser- vices available for communities• Shortages of motivated health workers and unwillingness of qualified health workers to work in remote areas.• Lack of awareness in the community of the full range of services that their PHC should provide for them.

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, needs, knowledge & attitudes) should be im-plemented before any action plan or budget is put forward for any community based initiate in RH.

Intensify community awareness raising on pregnancy danger signs and delivery pre-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.

•

•

•

•

•

More commitment is needed from the MoH to establish Basic EmOc services closer to the rural community (e.g incentives for doctors to work in rural communities).

More advocacy is required for task shifting among RH health personnel so as to improve maternal health in Sudan.

•

•

19