Midwives and donkey carts

When I met 26 year-old Zainab Usman in January in the health facility at the Kreneik Internally Displaced People’s camp in West Darfur, Sudan, she had malaria and was recovering from a miscarriage. Zainab had undergone a severe form of female genital mutilation when she was a child, had lost 2 babies due to obstructed births, had undergone two caesareans where the babies survived and this was her fifth pregnancy. She had started bleeding 10 days before reaching the Kreneik facility and needed 3 pints of blood to revive her. Normal haemoglobin levels for women should be 120 grams per litre; Zainab’s was just 35. Save the Children, with GSK’s support, is helping build a blood bank in the Kreneik facility, which will go a long way in saving the lives of women like Zainab.

There was no midwife in her village which was 20km away from Kreneik. The family had to borrow money to pay for Zainab to get there in a van, which was filled with goods for the market, ­ donkeys or donkey carts are the usual form of transport in the area. In the meantime, her baby had died and she had to undergo surgery to have the foetus removed.

In Sudan, government health expenditure as a percentage of GDP was 1.08% in 2014. Out-of-pocket expenditure as a percentage of total health expenditure has been steadily rising from 61.4% in 2004 to 75.5% in 2014. Regions such as West Darfur, which are a low government priority, receive far less allocations for health than they require, as the Kreneik facility highlights: serving a population of more than 37,000 people spread over 960 villages and hamlets, it has just 30 trained midwives who are both community and facility based.

Having travelled to Kreneik myself from Geneina, which took 3½ hours accompanied by armed escorts, I can vouch that there are hardly any roads, transport is sporadic ­­­- in the form of vans or donkey carts going to the Kreneik market ­- and the area is considered unsafe due to the presence of militia groups. This environment hardly encourages the 30 trained midwives attached to the Kreneik facility to travel between the spread-out villages. The work environment is harsh and does not encourage midwives to want to be based there -­ unless, of course, they are local. Security is a big concern; in fact the Kreneik facility’s ambulance was carjacked in 2014.

It’s challenges such as these that the 4,200 participants, mostly midwives, attending the International Confederation of Midwives (ICM) 2017 Congress  were trying to grapple with when the Congress took place in Toronto last month. The theme for the Congress was ‘Midwives: Making a Difference in the World’. Save the Children works with the ICM to highlight the important role of midwives, as health practitioners and as advocates, and the need for governments to invest in midwifery as a way of ending preventable maternal, newborn deaths and stillbirths and as a first step towards achieving Universal Health Coverage (UHC). We organised a high-level plenary session to highlight the need for more recognition and support of midwives and midwifery as a critical strategy of Every Woman Every Child through the Quality, Equity, Dignity movement. And we organised an interactive quiz on UHC to highlight the wide disparities in health investment between countries.

Test your knowledge of Universal Health Coverage with our quiz.

Chief Executive of the ICM Sally Pairman launched our new UHC Advocacy Toolkit. She went on to motivate the midwives who were present to become strong advocates for UHC and for them to urge their governments to invest in more midwives and save more lives.

Toronto is a world away from Sudan, and ICM’s Congress may seem irrelevant to the needs of women such as Zainab. Yet they are strongly linked. If this isn’t apparent, then it’s critical for organisations such as Save the Children to link them in a more obvious fashion.

We’ll continue to advocate for increased health financing and to assist countries to train more midwives, and deploy and retain them at the primary healthcare level, in an attempt to save the lives of more women like Zainab. We’ll build the capacity of midwife activists like those at the ICM to bring their stories and experiences to the global level and we’ll help build a movement for change that will ensure the needs of the most vulnerable will shape and lead health policies. And we’ll continue to engage with ICM and other global institutions and policy processes to help people understand that UHC is possible and that each and every one of us has a role to play in ensuring that the needs of women such Zainab drive global and national policy and planning ­ and contribute to women and children in all countries experiencing quality, equity and dignity in health.