Care in the desert
by Sean Deely
More than 1,600 women in Somalia die every day from pregnancy-
and childbirth-related complications.
In Somalia, a woman has a greater chance of dying during childbirth
than anywhere else in the world. The Somali Red Crescent has
devoted itself to reversing this tragic situation.
Fatima, a 17-year-old Somali woman, had been in labour for
over 48 hours when Rugiyo Ahmed Musa was called to see her.
Rugiyo is a midwife at the Somali Red Crescent Society's mother
and child health clinic (MCH) in Qarhis, in the north-east
of Somalia. Fatima had collapsed near the village after a
three-hour trek. Her husband carried her to a house in the
village and rushed to alert staff at the Red Crescent clinic.
This would be her first child. Like almost all Somali women,
Fatima had been subjected to circumcision during childhood
- or female genital mutilation. In this case, third degree
or pharaonic circumcision, where the
clitoris and labia are removed and the vagina sutured closed.
It is estimated that there are between 100 and 132 million
girls and women worldwide who have been subjected to this
Circumcision is usually done by a traditional birth attendant
or healer often using razor blades or rudimentary tools instead
of scalpels. As a consequence, safe childbirth requires an
episiotomy - a surgical procedure to open the vagina during
childbirth to allow the child to be born. Both lateral and
vertical incisions are frequently required.
Examining Fatima, Rugiyo found that she was eight centimetres
dilated, but the episiotomy performed by the local birth attendant
a few days earlier was insufficient. In this case only a vertical
incision had been made and the child was trapped in the birth
canal. Rugiyo made a second, lateral incision and assisted
with the birth.
Dying from inadequate health care
Midwife Serad Aden Mohamed, health officer at the Garowe
Red Crescent branch supervises seven National Society MCH
clinics. "We have many cases like this, because there
are few clinics, women - especially nomads -rely on traditional
birth attendants. Most of them have no formal training and
some don't even know the basics about when to cut the umbilical
cord, how to clean the baby's airway, or massage the chest.
When complications arise they don't know what to do."
Many women die in childbirth as a result - at 1,600 per 100,000
live births, the maternal mortality rate in Somalia is the
highest in the world. UNICEF estimates infant mortality at
132 per 1,000 live births and child mortality is as high as
224 per 1,000. Put simply, one child in every three dies before
they reach the age of five.
Plagued by major health problems from acute respiratory infections,
diarrhoea, measles and tuberculosis, Puntland's population
of over a million people is spread out over a geographical
area bigger than England, encompassing the north-east Somali
regions of Mudug, Nugal, Bari, Sool and the eastern part of
Sanaag. While the region is relatively calm, there are few
roads and fewer health facilities. An estimated 60 per cent
of this population is nomadic, which further complicates issues
of access to the limited number of health services that exist.
According to the director general of health in the regional
administration in Garowe, there are 63 qualified doctors registered
in Puntland, five functioning hospitals, three health centres,
25 MCH clinics, and 62 health posts (many of them not functioning).
In Qarhis, the range of health-care providers is typical
of most of Puntland. Apart from the traditional birth attendants,
there are five traditional healers in the village. Munina
Osman, 63 years of age, is one. Her grandfather was a well-known
traditional healer in the Qarhis area. Her grandmother was
also a traditional healer. "I learned a lot of things
about healing from them when I was young and have gained a
lot of experience since I became a traditional healer when
I was 20."
She has three main types of treatment: burning, cutting and
orally administered herbal potions. "I always burn when
there is a fever: it is necessary to stop the infection -
otherwise it will spread and cause long-term damage."
Sometimes she 'cuts' her patients. This involves making small
incisions at the point of pain - usually using a razor blade.
She stressed that burning and cutting are superficial and
that care is taken not to damage veins. Herbal 'medicine'
is prepared by mixing certain herbs and sheep lard to make
a potion that she prescribes to people with different ailments.
Additionally, there are two 'pharmacies' on the main street
where a variety of different clothing, cosmetic and medical
products are for sale. Stocks of medicine are very limited,
and the owners have no medical training.
The Qarhis health clinic is one of 45 primary health clinics
run by the Somali Red Crescent.
One child in three dies before they reach the age of five.
Contrasts from north to south
Since the collapse of central government in 1991, Somali
society has been plunged into a downward spiral of violence.
A low-intensity conflict persists in central-southern Somalia,
thus impairing development and recovery efforts and leaving
the population in a precarious environment. Elsewhere, in
the north-east the Puntland state enjoys relative stability.
The emergency response of the Movement includes food, non-food
and seed assistance. Being the only Somali structure that
can still claim a degree of national representation, the Somali
Red Crescent Society (SRCS) runs four hospitals and 45 primary
health centres throughout the country, with major assistance
from the ICRC and additional support from the Federation and
various National Societies.
Sustaining the service
In 1993 the Somali Red Crescent, supported by the Federation,
developed an integrated health-care programme within the mother
and child health/ outpatient clinics and health posts. In
the absence of a central health service the National Society
runs four hospitals and 45 primary health clinics throughout
the country serving 840,000 people with support from the ICRC
and the Federation. Twelve of these clinics are located in
the Puntland. Eight years on, the clinics provide a lifeline
for thousands of vulnerable mothers and children, in communities
like Qarhis - three hours' drive away from the nearest alternative
The Somali Red Crescent also provides medical supplies to
the clinics on a monthly basis. One kit of essential drugs
with no injectables, and a supply of vaccines. The vaccines
are essential in the battle to reduce child mortality. However
many of the clinics are without refrigeration facilities and
the cost is counted in lost opportunities to immunize nomadic
children who may make only one visit before their family moves
The National Society also offers training and special kits
to three traditional birth attendants each year, who then
work in close collaboration with the clinic. Last year, three
attendants received training in the Qarhis.
The Somali Red Crescent is dependent on outside aid from
the Federation, ICRC and the World Bank to run these clinics,
while UNICEF provides some drugs and training support for
clinic staff. Today, the challenge is how to convert an essentially
emergency-driven, relief health project, into a sustainable
service that meets the needs of communities recovering from
conflict and rebuilding their lives.
In a joint initiative between the Federation, the Somali
Red Crescent and the World Bank, a health-sector rehabilitation
study was done in April 2000. The purpose of it was to identify
a system to share the cost of maintaining the clinics between
those in the community who could afford to pay, the emerging
directorate of health in Puntland state's Ministry of Social
Affairs, and the international donors who have kept the programme
going since 1993.
The first phase of the study concluded in March 2001 with
the setting up of a one-year pilot project for sustaining
primary health service provision in Qarhis clinic. This project
establishes a partnership between the community in Qarhis,
the directorate of health in Puntland and the Somali Red Crescent.
Within this new project, the cost of running the clinic will
be shared among the three partners, with the National Society
and its donors assuming 80 per cent, the community 15 per
cent and the directorate of health 5 per cent.
Thankfully for Fatima, the clinic continues to function -
for now. The prolonged labour caused post-partum haemorrhaging
or internal bleeding. The midwife, Rugiyo, had ergometrine
on hand to contract the uterus and stem the bleeding. Neither
diagnosis nor treatment would have been available from a traditional
birth attendant. "We don't know what would have happened
if the midwife had not been available today, but probably
both Fatima and her child would have died" said Serad
Aden Mohamed, health officer at the Garowe Red Crescent branch.
Sean Deely is senior officer for post-disaster recovery in
the Federation's disaster preparedness and response department.
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